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CASE HISTORIES 



!N 



PEDIATRICS 



A COLLECTION OF HISTORIES OF ACTUAL PATIENTS 

SELECTED TO ILLUSTRATE THE DIAGNOSIS, 

PROGNOSIS AND TREATMENT OF THE 

MOST IMPORTANT DISEASES OF 

INFANCY AND CHILDHOOD. 



BY 
JOHN LOVETT MORSE, A.M., M.D. 

Assistant Professor of Pediatrics, Harvard Medical School; Associate Visiting Physician at 
the Infants' Hospital and at the Children's Hospital, Boston. 



BOSTON 

W. M. LEONARD 
1911 






Copyright, iqii, 
By W. M. Leonard. 



CI.A280759 



TO 

THOMAS MORGAN ROTCH, M.D.. 

THE FATHER OF PEDIATRICS IN NEW ENGLAND. 

THE ORGANIZER OF 

THE DEPARTMENT OF PEDIATRICS 

IN THE 

HARVARD MEDICAL SCHOOL 

AND THE 

FOUNDER OF MODERN SCIENTIFIC INFANT FEEDING. 



PREFACE. 



The author has found this method of case teaching so useful in 
the instruction not only of undergraduates but also of graduate 
students, who, although older and wiser than in their undergraduate 
days, are still students in the best and widest sense, that he felt 
that there was need for the utilization of this method for the 
presentation of the subject of pediatrics to the practitioner. 

Case teaching, which had been in use for a number of years in 
the Harvard Law School, was introduced into the Harvard Medical 
School in 1900 at the suggestion of Prof. W. B. Cannon, then a 
student in the school. The author believes that this method of 
teaching is far superior to recitations, quizzes, and conferences. 
One of its greatest advantages is that it compels the student to 
think for himself. It is almost as valuable as the clinical lecture, 
in which the patient is shown, and, except in special instances, is 
more instructive than the didactic lecture. It is surpassed only 
by bedside instruction to small groups of students. 



TABLE OF CONTENTS. 



Diseases of the New-born. page. 

Case i. Icterus Neonatorum . 12 

2. Obstetric Paralysis 14 

3. Congenital Atelectasis 17 

4. Cephalhematoma 20 

5. Hemorrhagic Disease of the New-born 22 

6. Septic Infection of the New-born 26 

7. Congenital Obliteration of the Bile Ducts 28 

8. Encysted Hydrocele of the Cord 30 

9. Congenital Stridor ,,,,,,,, 32 

Diseases of the Gastro-Enteric Tract. 

Case 10. Infantile Pyloric Stenosis 38 

11. Nervous Vomiting 41 

12. Recurrent Vomiting 43 

13. Acute Gastric Indigestion 47 

14. Chronic Gastric Indigestion 50 

15. Intussusception 54 

16. Intussusception 57 

17. Constipation of Spasmodic Type. Fissure of Anus .... 60 

18. Constipation from Excess of Fat in Food 63 

19. Acute Duodenal Indigestion 65 

20. Chronic Duodenal Indigestion 68 

21. Acute Intestinal Indigestion 71 

22. Chronic Intestinal Indigestion 74 

23. Acute Gastric and Intestinal Indigestion from Excess of 

Sugar in Food 77 

24. Indigestion from Excess of Fat in Food 79 

25. Indigestion from Excess of Proteids in Food 82 

26. Appendicitis 85 

2j. Appendicitis 88 

28. Infectious Diarrhea — Dysenteric Type 91 

29. Infectious Diarrhea — Cholera Infantum 94 

Diseases of Nutrition. 

Case 30. Malnutrition from an Insufficient Amount of Food .... 97 

31. Malnutrition from an Insufficient Amount of Proteids in 

Food 101 

32. Rickets 104 

33. Scurvy 108 

34. Scurvy 112 

35. Infantile Atrophy 114 

7 



8 TABLE OF CONTENTS. 

Specific Infectious Diseases. page. 

Case 36. Tubercular Peritonitis 117 

37. Tubercular Peritonitis : . 121 

38. Tubercular Meningitis 124 

39. Cerebrospinal Meningitis 128 

40. Cerebrospinal Meningitis 131 

41. Typhoid Fever 134 

42. Nasal Diphtheria 137 

43. Laryngeal Diphtheria 139 

44. Influenza 142 

45. Malaria 144 

46. Osteomyelitis 146 

47. Congenital Syphilis , , , , , , , , , , , 148 

Diseases of the Nose, Throat, Ears and Larynx. 

Case 48. Adenoids 153 

49. Adenoids 155 

50. Retropharyngeal Abscess 157 

51. Otitis Media 160 

52. Otitis Media 162 

53. Laryngismus Stridulus 164 

54. Catarrhal Laryngitis , 167 

Diseases of the Bronchi, Lungs and Pleura. 

Case 55. Acute Bronchitis — Mild 169 

56. Acute Bronchitis — Severe 171 

57. Bronchopneumonia 173 

58. Lobar Pneumonia 176 

59. Lobar Pneumonia 180 

60. Serous Pleurisy 183 

61. Purulent Pleurisy , 187 

Diseases of the Heart and Pericardium. 

Case 62. Congenital Heart Disease 191 

63. Functional Heart Disease 194 

64. Myocarditis 197 

65. Acute Endocarditis 200 

66. Pericarditis with Effusion 203 

67. Chronic Adhesive Pericarditis ...,....,,,.. 207 

Diseases of the Liver. 

Case 68. Fatty Liver 211 

69. Cirrhosis of the Liver 214 

70. Sarcoma of the Liver 217 

Diseases of the Kidneys and Bladder. 

Case 71. Orthostatic Albuminuria 219 

72. Hematuria 222 



TABLE OF CONTENTS. 9 

PAGE. 

73. Acute Nephritis 224 

74. Pyelitis 230 

75. Pyelitis 233 

76. Sarcoma of the Kidney 235 

Diseases of the Blood. 

Case 77. Secondary Anemia — Chlorotic Type 237 

78. Secondary Anemia 240 

79. Secondary Anemia with Splenic Tumor 243 

80. Lymphatic Leukemia 247 

81. Lymphatic Leukemia 250 

82. Anemia with Splenic Tumor 252 

Diseases of the Nervous System. 

Case 83. Habit Spasms 257 

84. Epilepsy 260 

85. Reflex Convulsions 263 

86. Mongolian Idiocy 266 

87. Amaurotic Idiocy 269 

88. Tetany 272 

89. Cerebral Hemorrhage of the New-born 275 

90. Cerebral Paralysis 278 

91. Encephalitis 280 

92. Infantile Paralysis 284 

93. Infantile Paralysis 286 

94. Cerebellar Tumor 289 

95. Diphtheritic Paralysis 292 

96. Hysterical Paralysis , , 294 

Unclassified Diseases. 

Case 97. Cretinism 297 

98. Angioneurotic Edema 300 

99. Purpura 303 

100. Diabetes Mellitus 307 



SECTION I. 
DISEASES OF THE NEW-BORN. 



12 CASE HISTORIES IN PEDIATRICS. 

CASE I. Sidney K. was the first child of healthy parents. 
There was no history of syphilis and there had been no mis- 
carriages. He was born May 28, about a week premature. 
He weighed six pounds and was put at once on a weak 
modified milk. Jaundice developed on the second day and 
became very marked. He took his food well and had not 
vomited. The movements consisted at first of meconium; 
later the bowels were very constipated, but the movements 
were yellow and smooth. The temperature was normal or 
slightly subnormal. The urine had not stained the diapers. 
He was seen in consultation June 5, when eight days old. 

Physical Examination. He was small and somewhat emaci- 
ated, having lost a pound. There was deep jaundice of the 
skin and conjunctivae. He did not seem especially feeble. 
The fontanelle was level. The mouth and throat were nor- 
mal. The heart, lungs and abdomen were normal. The 
umbilicus was healed. The liver was palpable 2 cm. below 
the costal border in the nipple line. The spleen was not 
palpable. The extremities were normal; there was no 
spasm or paralysis; the knee-jerks were equal and normal. 
The genitals were normal. There were no ulcerations about 
the anus. There was no eruption or enlargement of the periph- 
eral lymph nodes. The rectal temperature was normal. 

The urine was not examined, but the diapers were not 
stained by it. 

The movements were small, constipated, brownish-yellow 
and well-digested. 

Diagnosis. When jaundice develops during the first few 
days of life it is always a temptation to call it icterus neona- 
torum and to dismiss it without further consideration. There 
are other causes of jaundice at this age, however, and while a 
snap diagnosis of icterus neonatorum will be correct in the 
vast majority of cases, it will occasionally be wrong, and 
wrong often enough to justify a careful differential diagnosis 
in every instance. The diseases to be considered are, septic 
infection of the newborn, congenital obstruction or oblitera- 
tion of the bile ducts, acute duodenal indigestion, congenital 
syphilis and congenital icterus. 

The early appearance of the jaundice, the presence of deep 



DISEASES OF THE NEW-BORN. 13 

jaundice without cyanosis, the good general condition and 
the absence of fever and of enlargement of the liver and spleen 
rule out septic infection of the newborn. The absence of 
enlargement of the liver and spleen and of bile in the urine, 
together with the presence of bile in the stools, rule out 
congenital obliteration of the bile ducts. Acute duodenal 
indigestion is very uncommon at this age. It is excluded by 
the absence of bile in the urine and the presence of bile in the 
stools. Congenital syphilis is suggested by the prematurity. 
There are, however, other causes for prematurity than syphi- 
lis. The good family history and the absence of miscarriages 
are against it. The normal size of the liver and spleen, 
together with the absence of all signs of syphilis, rule it out. 
Congenital icterus is an extremely rare condition and is 
excluded because the jaundice was not present at birth and 
the spleen is not enlarged. The diagnosis by exclusion is, 
therefore, Icterus Neonatorum. The development of the 
jaundice on the second day, the good general condition, 
the presence of bile in the stools, its absence in the urine, 
the normal temperature and the absence of enlargement of 
the liver and spleen are all consistent with this diagnosis. 

Prognosis. Icterus neonatorum does not affect the general 
condition. The jaundice will probably not increase in in- 
tensity, but will not disappear entirely for several weeks. 

Treatment. No treatment is indicated. Icterus neona- 
torum is a physiological condition and is due to the mere 
mechanical difficulty which the bile encounters in passing 
through the bile capillaries. There is, therefore, no object 
in. giving cathartics. Cleaning out the intestine cannot 
affect the conditions in the bile capillaries. It has been shown 
that calomel, like the other so-called " cholagogues," does 
not increase the flow of bile. If it did, it would be contra- 
indicated rather than indicated in this condition. There is 
no indication for changing the food, because sufficient bile 
to carry on digestion enters the intestine, only the excess 
passing into the circulation. 



14 CASE HISTORIES IN PEDIATRICS. 

CASE 2. William P. was the second child of healthy par- 
ents. The position was 0. D. P. He was delivered by high 
forceps and weighed eleven pounds. The physician in charge 
pulled very hard on one shoulder, probably the right, during 
the delivery, and thought that he felt something give way. 
The baby was somewhat white at birth, did not respond to 
artificial respiration, and mouth-to-mouth insufflation was 
necessary. He then cried and seemed perfectly normal 
except that it was noticed at once that there was some 
trouble with the face and the right arm. He did not close 
the right eye and there was no motion of the right side of 
the face. The right arm hung limp at the side and was used 
but little. There had been some improvement in the condi- 
tion of both face and arm. He was seen in consultation when 
one week old. He was not nursed, but took the bottle well 
and had no disturbance of digestion. 

Physical Examination. He was well-developed and nour- 
ished. His color was good. The fontanelle was 3 cm. in 
diameter and level. The head was of good shape. There 
was no rigidity of the neck. There was a hemorrhage into 
the right conjunctiva. The pupils were equal and reacted 
to light. The left eye could be closed entirely; the right 
only partially. The mouth was drawn to the left when he 
cried. There were forceps scars on the left forehead, but none 
on the right. The heart and lungs showed nothing abnormal. 
The level of the abdomen was that of the thorax. The cord 
was still on, but was healthy. The liver was palpable 3 cm. 
below the costal border in the nipple line ; the spleen was not 
palpable. The genitals were normal. The right arm hung 
limply by the side, extended at the elbow and wrist, and with 
the palm turned backward. He made no active motions 
with this arm except at the wrist and with the fingers. His 
grip was strong. Passive motions were not limited. The 
arm was not tender, and there were no evidences of fracture 
or dislocation. The left arm and the legs were normal and 
showed no signs of spasm or paralysis. The knee-jerks were 
equal and lively. There was no Kernig's sign. There was 
no enlargement of the peripheral lymph nodes. The rectal 
temperature was normal. 



DISEASES OF THE NEW-BORN. 



15 



Diagnosis. The diagnosis of facial paralysis is evident. 
The inability to close the eye shows that the upper branch 
of the facial is involved and that the paralysis is, therefore, 
peripheral in origin. It was undoubtedly caused by the 
pressure of the forceps blade on the trunk of the nerve. 
The hemorrhage into the right conjunctiva is presumably 
also due to injury from the forceps blade. 

The flaccidity of the right arm at once rules out cerebral 
paralysis, in which the paralysis is spastic. Moreover, in 
cerebral paralysis due to injury at birth, the paralysis is 
never limited to one extremity, and if an extremity is affected, 





Fig. 



Facial Type. Case 2. 



Fig. 2. Arm Type. Case 2. 



it is always affected as a whole, not in part. If the baby was 
older, infantile paralysis (poliomyelitis) might be considered, 
but, as the paralysis was present at birth, is an impossi- 
bility. It corresponds perfectly to the so-called " obstetric 
paralysis " of the upper- arm type, in which there is a paralysis 
of certain muscles from injury to the brachial plexus during 
labor. The stretching of the plexus caused by the pulling 
on the shoulder was presumably the cause in this instance. 
The characteristic position of the arm is due to the fact that 
only certain muscles are involved, namely, the deltoid, bi- 
ceps, brachialis anticus, supinator longus, infraspinatus, 
supraspinatus and serratus magnus. 



1 6 CASE HISTORIES IN PEDIATRICS. 

This baby, therefore, shows both the facial and arm types 
of Obstetric Paralysis. 

Prognosis. The prognosis of the facial paralysis is almost 
absolutely good. Recovery almost invariably takes place in 
a few weeks. 

The prognosis of the paralysis of the arm is not as good. 
There will certainly be a great deal of improvement, but 
equally certainly some permanent disability. How great 
this disability will be cannot be told for a year or two, after 
which time little improvement can be expected. 

Treatment. The facial paralysis requires no treatment. 
The only treatment indicated for the arm at present is a 
sling to take the weight of the arm off the shoulder muscles. 
Massage and electricity may be begun in about three weeks. 
The object of them both is to keep up the tone of the muscles 
until the nerves regain their power. Faradism should be 
used, if the muscles react; if they do not, galvanism. If, 
at the end of a year, there has been but little improvement, 
operation on the nerve trunks is worthy of consideration. 



DISEASES OF THE NEW-BORN. 1 7 

CASE 3. Catherine E. was delivered at full-term by low 
forceps after a long labor, and weighed nine pounds. Her 
mother had been married twice. Her only pregnancy by 
her first husband had resulted in a miscarriage at two or 
three months, after an accident. She thought that he had 
not had syphilis and had had no symptoms of it herself. 
Her second husband denied having had syphilis. The 
patient was the first child by the second husband. She is 
said to have cried vigorously immediately after birth. The 
nurse noticed, a few hours later, however, that she did not 
breathe naturally. The trouble with the breathing continued. 
When quiet, she breathed quickly and her color was fair. 
If disturbed, or if she made any exertion, she usually became 
very cyanotic. Sometimes she at first became very pale and 
then cyanotic. She seldom cried. The respiration was never 
noisy. She usually kept her mouth shut and was able to 
suck. She had apparently never had any fever and had never 
had any disturbance of the digestion. She was seen in con- 
sultation when about five weeks old. 

Physical Examination. She was fairly developed and nour- 
ished. When quiet, she breathed quickly but quietly. The 
alse nasi did not move, she kept her mouth shut and her 
color was good. There was, however, moderate retraction of 
the epigastrium and of the sides of the chest. When dis- 
turbed, the respiration became more rapid and labored, but 
not noisy. She kept her mouth open and was evidently 
distressed. She tried to cry but was unable to make much 
noise. She became very cyanotic, and the retraction of the 
epigastrium and sides of the chest was much increased. A 
probe was easily passed through both nostrils. There were 
no snuffles. The throat was normal both to inspection and 
palpation and no adenoids were felt with the finger. There 
was no increase of the thymus dullness, and the thymus 
could not be felt in the suprasternal notch. The cardiac 
impulse was indistinctly palpable in the fourth left space 
Si cm. to the left of the median line. The right border of 
dullness was 2 cm. to the right of the median line. The action 
was regular; the rate varied between 140 and 180 according 
to the difficulty in breathing. The sounds were normal in 



1 8 CASE HISTORIES IN PEDIATRICS. 

character and there were no murmurs. There was marked 
dullness and diminished broncho-vesicular (much nearer 
vesicular than bronchial) respiration, with an occasional 
medium moist rale in the left front down to the cardiac area 
and in the upper left axilla, and over the whole right back 
except at the apex. There was hyperresonance and exagger- 
ated vesicular respiration over the rest of the lungs, and 
numerous fine moist rales were heard. The abdomen was 
normal. The liver was palpable 2 cm. below the costal border 
in the nipple line; the spleen was not palpable. The ex- 
tremities were normal. There was no spasm or paralysis. 
The knee-jerks were equal and normal. There was no en- 
largement of the peripheral lymph nodes. There was no 
eruption and no scars of any old eruption. There were no 
mucous patches about the anus. The rectal temperature 
was normal. 

Diagnosis. The problem is to find the cause of the diffi- 
culty in respiration and cyanosis. This cause is the diagnosis. 
The physical examination rules out obstruction in the nose, 
nasopharynx, pharynx and larynx, as well as pressure from 
an enlarged thymus. The heart shows nothing abnormal. 
Sometimes, however, the examination of the heart shows 
nothing abnormal in congenital heart disease even when 
there are marked symptoms. The signs in the lungs are so 
definite in this instance, however, that it is not necessary to 
take refuge in this explanation. The signs in the lungs show 
partial solidification. The possible explanations of this 
solidification are resolving pneumonia, syphilis of the lung 
and congenital atelectasis. 

Resolving pneumonia is mentioned merely because this 
was the diagnosis of another consultant. It can at once be 
ruled out because there was never any fever and the symptoms 
appeared within a few hours after birth. Syphilitic involve- 
ment of the lung sufficient to give such marked physical 
signs is very unusual and is found only in the severest cases 
in which there are many other signs of the disease. The 
negative family history and the lack of any other signs of 
syphilis rule it out in this instance. The early appearance 
and the persistence of the symptoms without fever are most 



DISEASES OF THE NEW-BORN. 1 9 

characteristic of atelectasis. The only point against it is 
that the baby is said to have cried vigorously at birth. This 
jnay have been an error of observation, but, if true, does not 
rule out atelectasis, because it is perfectly possible for a 
baby to cry loudly and yet not completely expand the lungs. 
The diagnosis is, therefore, Congenital Atelectasis. The 
fine moist rales heard over the rest of the lungs are undoubt- 
edly due to edema. 

Prognosis. The prognosis is very grave. There is very 
little chance of expansion of the atelectatic areas after five 
weeks, and the child cannot live long in its present condition. 

Treatment. There is no direct treatment for the atelecta- 
sis. The best that can be done is to feed the baby carefully, 
give it plenty of fresh air, administer oxygen when there is 
cyanosis, and stimulate it, if necessary. 



20 CASE HISTORIES IN PEDIATRICS. 

CASE 4. Harriott H., the first child of healthy parents, 
was born at full-term after a difficult forceps delivery, and 
weighed eight pounds. She breathed at once and seemed 
normal in every way except that her head was much swollen 
and out of shape. The general swelling went down in twenty- 
four hours and then a circumscribed swelling was noticed on 
the right side of the head. This had diminished a little in 
size and had apparently caused her no discomfort. She had 
seemed normal in every way except for the swelling on the 
head. She was seen in consultation when a week old. 

Physical Examination. She was well developed and nour- 
ished and of good color. There was a swelling, the size of a 
duck's egg, over the right parietal bone. This swelling was 
soft and fluctuating, but neither red nor tender. Pressure on 
it caused no bulging of the anterior fontanelle and no dis- 
comfort or signs of increased cerebral pressure. It did not 
extend beyond the borders of the right parietal bone. The 
pupils were equal and reacted to light. There was no rigidity 
of the neck. The anterior fontanelle was level. The heart, 
lungs and abdomen were normal. The liver was palpable 
2 cm. below the costal border in the nipple line; the spleen 
was not palpable. The extremities were normal; there was 
no spasm or paralysis; the knee-jerks were equal and normal; 
there was no Kernig's sign. 

Diagnosis. This tumor corresponds in every way to a 
Cephalhematoma and undoubtedly is one. The caput 
succedaneum is hard, does not fluctuate and is not limited to 
a single bone. It disappears in from twenty-four to forty- 
eight hours. The swelling first noticed in this instance was 
undoubtedly a caput. A meningocele protrudes through one 
of the normal openings in the skull, a fontanelle or suture, 
and is most often situated at the root of the nose or in the 
occipital region. Pressure on it causes bulging of the anterior 
fontanelle, discomfort and symptoms of increased cerebral 
pressure, such as spasm or twitching of the extremities. An 
abscess is hot, red and tender, and is accompanied by fever 
and symptoms of general constitutional disturbance. 

Prognosis. The prognosis is absolutely good if the tumor 
is let alone. It is sure to disappear in from three to six weeks. 



DISEASES OF THE NEW-BORN. 



21 



If it is aspirated or opened it may become infected and an 
abscess result. 

Treatment. The treatment is to let it alone. External 
applications cannot hasten the absorption of the blood. 
Aspiration will hasten the disappearance of the tumor, but 
is unnecessary and carries with it the danger of infection. 
An incision is unnecessary, will leave a scar and is very likely 
to result in infection and the formation of an abscess. 




Fig. 3. Harriott H. Cash 



22 CASE HISTORIES IN PEDIATRICS. 

CASE 5. John B. was the first child of healthy parents, 
except that his mother had always been anemic. There had 
been no miscarriages. His father denied syphilis and showed 
no signs of having had it. There had never been any " bleed- 
ers " in either family. He was delivered at 6 a.m., August 4, 
at full term, by low forceps, after a short labor, and weighed 
nine pounds. He was normal except for a slight abrasion on 
the right cheek and another on the back of the neck, and 
breathed at once. He was put to the breast that afternoon, 
took hold well, but got nothing. The next morning he was 
ordered one-half ounce of a mixture containing 1% of fat, 
5% of sugar, 0.25% of whey proteids and 0.25% of casein 
every two hours, but as this was vomited it was stopped 
after three feedings. Since then he had had only boiled 
water. Oozing of blood began about midnight, August 5, 
from both abrasions, and a hematoma, the size of half a 
walnut, appeared at the site of each of them. The oozing 
continued and he lost about half an ounce of blood during 
the night. The bleeding was then controlled by pads soaked 
in a 1-10,000 solution of adrenalin chloride. Several small 
hemorrhagic areas appeared in the roof of the mouth and one, 
the size of a dime, on the back that morning, August 6. 
He had not vomited blood or had any blood in his movements. 
The highest rectal temperature was 99 F. He had been given 
10 ccm. of fresh rabbit's serum at 3.30 p.m., August 6. He 
was seen in consultation at 5 p.m. 

Physical Examination. He was well developed and nour- 
ished, but moderately pale. The respiration was a little 
rapid. He seemed uncomfortable and was inclined to moan. 
The fontanelle was level. There was no rigidity of the neck. 
There were slight ecchymoses in the right eyelids. There 
were several ecchymotic areas, varying in size from that of a 
split pea to that of a twenty-five cent piece, on the upper 
part of the right cheek. There was an abrasion, about 2 cm. 
long and 1 cm. wide, over the largest ecchymosis, where there 
was also some swelling. It was scabbed over and not oozing. 
There was an ecchymotic area, the size of a twenty-five cent 
piece, on the back of the left neck, where there was also a 
scab, but no oozing. There was an ecchymotic area, the size 



DISEASES OF THE NEW-BORN. 23 

of a ten-cent piece, on the lower back, and half a dozen ecchy- 
motic areas, the size of a pinhead or a little larger, in the 
roof of the mouth. The heart and lungs were normal. The 
abdomen was negative. There was no bleeding from the 
stump of the cord. The liver was palpable 3 cm. below the 
costal border in the nipple line; the spleen was not palpable. 
The extremities were normal ; there was no spasm or paraly- 
sis; the knee-jerks were equal and normal; Kernig's sign was 
absent. There was no enlargement of the peripheral lymph 
nodes. There was no bleeding from the point where the 
rabbit's serum was injected. 

The movements which were seen were loose, dark-green 
and contained considerable mucus, but no blood. 

Diagnosis. The diseases to be considered here are congeni- 
tal syphilis, hemophilia and hemorrhagic disease of the new- 
born. Syphilis can be excluded on the negative family his- 
tory, the absence of miscarriages, the good general condition, 
the absence of all signs of syphilis, such as enlargement of 
the liver and spleen and eruptions, and the fact that hemor- 
rhage occurs only in the severest cases which show many 
other signs of the disease. Hemophilia can be excluded on 
the family history and the fact that the tendency to bleed in 
hemophilia almost never appears before the end of the first 
year. Larrabee, writing in 1906, was able to collect but 
thirty-six cases of hemorrhage in the newborn due to hemo- 
philia, and in all but two of these there was a family history 
of the disease. The diagnosis is, therefore, Hemorrhagic 
Disease of the New-born. 

Prognosis. The condition is, in general, a very serious one. 
Sixty per cent, or more, of the patients die, one half of them 
in the first twenty-four hours after the onset of the bleeding. 
If they survive a week they almost invariably recover. The 
symptoms cease in the first five days in two thirds of the 
cases that recover. The cases in which there is hemorrhage 
from the gastro-intestinal tract and in which there is a high 
temperature are more serious than those in which there is 
no gastro-intestinal hemorrhage and in which the tempera- 
ture is low. 

The following prognosis seems justified in this instance. 



24 CASE HISTORIES IN PEDIATRICS. 

The baby has a very serious disease. It is impossible to say 
whether or not the hemorrhages will recur or others appear. 
The outlook is, however, fairly good because he has already 
lived seventeen hours, there has been no hemorrhage for 
several hours, the bleeding is all external where it can be 
reached, and the temperature is normal. Every day that he 
lives increases his chances materially. There is no reason to 
fear recurrence in after years because this is a self-limited 
condition and not the disease hemophilia. 

Treatment. It is very difficult to know just how to treat 
the condition known as hemorrhagic disease of the newborn, 
because it is probably not a definite disease, but merely a 
combination of symptoms due to a variety of causes, the most 
common of which is presumably sepsis. The only definite 
point in the pathology is that the blood coagulates very slowly, 
or not at all. It is very probable, too, that the delay in the 
coagulation is due to the lack of something in the blood and 
not to the presence of some inhibitory substance. 

Most of the methods employed in the past in the treat- 
ment of this disease have recently been proved to be useless. 
Ergot and iron cannot, of course, have any effect in increasing 
the coagulability of the blood. Adrenalin has practically no 
action unless given intravenously. Its action is then general 
and not local, and the increase of the blood pressure would 
tend to increase rather than to diminish the bleeding. Gelatine 
does not increase the coagulability of the blood either in 
vitro or in viro. There is no lack of calcium salts in the blood 
in these cases and, therefore, the administration of calcium 
salts can do no good. 

A more rational treatment is the subcutaneous injection of 
fresh animal serum, preferably rabbit's, which contains all 
the ferments of the blood. Theoretically it would seem as if 
this could not do any good, because the blood contains anti- 
ferment enough to much more than neutralize the ferment 
contained in the ordinary doses of serum before it can be 
utilized in coagulation. Practically, it has seemed very 
useful in a considerable number of cases. 

The most rational method of treatment is transfusion, 
which not only replaces the lost blood but stops the hemor- 



DISEASES OF THE NEW-BORN. 25 

rhage by supplying new material for the production of the 
fibrin ferment. It has proved most satisfactory in the few 
cases in which it has been used. Before performing trans- 
fusion, however, it is necessary to be sure that the donor's 
blood does not produce hemolysis. Transfusion is a serious 
operation for both parties, and should not be undertaken 
lightly but only as a last resort. It must not on this account, 
however, be delayed too long. 

This baby has already had an injection of rabbit's serum. 
If the hemorrhage recurs, it should be repeated in six or eight 
hours and again at the same interval, if necessary. If the 
serum fails to restrain the hemorrhage in these doses, or if at 
any time the baby's condition is becoming at all critical, 
transfusion should be done. The preferable donor is the 
father. 

Locally, the adrenalin solution should be continued in 
connection with pressure. If this fails to stop the bleeding, 
the strength of the solution may be increased to 1-1,000, or 
the dry powder used. If this is not effective, Monsel's salt 
and pressure may be tried. 

The baby should be given one to two teaspoonfuls of a 
mixture of one part of breast milk to three parts of water, or 
whey, every hour. 



26 CASE HISTORIES IN PEDIATRICS. 

CASE 6. Baby G. was born at full term after a normal 
labor. He seemed healthy at birth but was not carefully 
examined. He was taken care of by a woman ignorant of the 
ordinary rules of cleanliness. The cord came off on the 
seventh day. The navel was healthy and at no time, before 
or after, was there any redness or inflammation about it. 
He was breast-fed and did very well until he was five days 
old, when he began to vomit a little and act as if he had pain 
in the abdomen. The vomiting and pain continued and 
increased in severity. He also began to have two or three 
loose yellow movements, containing fine curds and having a 
foul odor, daily. When he was nine days old a swelling, which 
seemed tender, was noticed in the epigastrium. The swelling 
in the epigastrium increased and by the twelfth day the 
whole abdomen was distended. He had apparently begun 
to have fever on the eighth day, but the temperature had not 
been taken. He was seen in consultation when two weeks 
old. 

Physical Examination. He had evidently lost much weight 
and his color was pasty. His face bore an expression of 
suffering. The fontanelle was depressed. There was no 
rigidity of the neck. The pupils were equal and reacted to 
light. The tongue was dry and covered with a brownish 
coat. The heart and lungs were normal. The upper border 
of the liver flatness in the nipple line was at the fourth rib; 
the lower border was not palpable. The spleen was not 
palpable. The navel was healthy and there was no redness 
about it. The abdomen was generally considerably dis- 
tended, but distinctly more so in the epigastrium. It was 
everywhere tympanitic, except over an area, the size of a 
silver dollar, in the median line midway between the tip of 
the ensiform and the navel. There was a marked sense of 
resistance in and about this area, but no definite muscular 
spasm. Tenderness was general throughout the abdomen, 
but much more marked over the resistant area in the epigas- 
trium. There was no dullness in the flanks and no fluid 
wave. The legs were drawn up on the abdomen and exten- 
sion caused additional pain. It was impossible to determine 
the presence or absence of the knee-jerks or Kernig's sign 



DISEASES OF THE NEW-BORN. 2J 

because of the baby's resistance. There was no enlargement of 
the peripheral lymph nodes. The rectal temperature was 
104 F., the pulse 160, the respiration 60. 

Diagnosis. The trouble is undoubtedly located in the 
abdomen. The liver is displaced upward. The fact that the 
baby is breast-fed and the mildness of the symptoms of in- 
digestion in comparison with the high temperature, poor 
general condition and marked, local symptoms show that the 
trouble is outside the gastro-intestinal tract. The situation 
of the local symptoms and the age of the baby make ap- 
pendicitis very improbable. The two possibilities are an 
inflammatory process, probably a localized abscess in the 
epigastrium, or a general peritonitis. The localization of the 
physical signs in the epigastrium and the absence of general 
muscular spasm and free fluid in the abdomen are much 
against general peritonitis and in favor of a localized abscess. 
A white count was not made because it could not help in the 
diagnosis, since both conditions are associated with leucocy- 
tosis. An inflammatory process in the upper or middle abdo- 
men at this age is almost invariably due to infection through 
the navel. The navel in this instance shows no signs of 
inflammation at present, and has shown none in the past. 
This does not rule out infection through the navel, however, 
as it is not uncommon for this to occur without causing any 
local manifestations. The known ignorance and the unclean- 
liness of the woman who took care of the baby make an 
infection through the navel seem even more likely. The 
most reasonable diagnosis is, therefore, a localized inflam- 
matory process, probably an abscess, in the epigastrium, as 
the result of an infection through the navel, i. e., a Septic 
Infection of the New-born. 

Prognosis. The prognosis is hopeless without an operation, 
practically hopeless with one. 

Treatment. The only treatment which offers any chance 
of recovery is an immediate laparotomy. 



28 CASE HISTORIES IN PEDIATRICS. 

CASE 7. Martha R., the third child of healthy parents, 
was born at full term after a normal labor and was apparently 
normal at birth. She was seen when three and a half months 
old. She was breast-fed entirely for two weeks, given one 
part of whole milk and two parts of water in addition for two 
months, then milk and water alone. Her weight at birth 
was not known, but she had evidently gained a little. The 
movements had been whitish in color from the first. Jaundice 
was first noticed when she was ten or twelve days old and 
had persisted, with a certain amount of increase, ever since. 
It was thought that the urine was light-colored in the begin- 
ning, but that it very soon became greenish and had so 
continued. The abdomen was large at birth and had so 
remained. The baby had seemed fairly well on the whole, 
but had vomited occasionally and had had two loose white 
movements daily. It was thought that she had had a little 
fever from time to time. 

Physical Examination. She was fairly developed and nour- 
ished. There was marked jaundice of the skin, mucous 
membranes and conjunctivae. The anterior fontanelle was 
4 cm. in diameter and level. She was perfectly intelligent. 
The mouth and throat were normal, and there were no snuf- 
fles. There was no rosary. The heart and lungs were normal. 
The upper border of the liver flatness was at the upper border 
of the fifth rib in the nipple line. The lower border of the 
liver was palpable, running from the right anterior superior 
spine to the left costal border in the nipple line. The notch 
was indistinctly palpable in the median line; the edge was a 
little rounded, the surface smooth. The gall bladder was not 
felt. The spleen was palpable, running out from beneath 
the costal border in the anterior axillary line, downward to 
the level of the navel, and backward and upward under the 
ribs in the posterior axillary line. It extended 4 cm. below 
the costal border and was 6 cm. wide. There was a moderate- 
sized umbilical hernia. There were no signs of fluid in the 
abdomen and no other masses were felt. The abdomen was 
not distended, except by the enlarged liver and spleen. 
Rectal examination was negative. The cervical lymph nodes 
were slightly enlarged; the axillary and inguinal were not. 



DISEASES OF THE NEW-BORN. 29 

There was a slight intertrigo about the buttocks and genitals, 
but no lesions of scratching. There were no mucous patches 
and no scars of any old eruption. The extremities were 
normal. The weight was nine pounds. 

The urine was greenish in color, of a specific gravity of 
1,009, an d acid in reaction. It contained no albumin but 
considerable bile. 

The stools were somewhat loose, grayish- white in color, 
foul in odor. Examination by the corrosive sublimate test 
showed a total absence of bile. 

Diagnosis. The history, physical examination, urine and 
stools together present such a characteristic picture of 
Congenital Obliteration of the Bile Ducts that a 
differential diagnosis is hardly necessary. The only other 
things to be considered as possibilities are congenital syphilis 
and duodenal indigestion. Enlargement of the liver and 
spleen, sometimes accompanied by jaundice, do occur in 
congenital syphilis. The absence of bile in the stools and of 
other signs of syphilis, such as snuffles, mucous patches and 
the scars of old eruptions, exclude it in this instance. Duo- 
denal indigestion is extremely unusual at this age, the liver 
but little enlarged, the spleen not at all. It can, therefore, 
also be ruled out. An important point to be remembered in 
this connection is the fact that there is a colorless form of 
bile, leucohydrobilirubin. It is never safe, therefore, to con- 
clude absolutely, without a chemical test, that a stool does 
not contain bile, even if it is white or clay-colored. 

Prognosis. The prognosis is absolutely hopeless. No case 
has lived to be more than eight months old. Death occurs 
from debility, secondary hemorrhage or intercurrent disease. 

Treatment. There is no curative treatment. The patients 
probably live longer and certainly digest better and are more 
comfortable, however, if fat is eliminated from their food. 



30 CASE HISTORIES IN PEDIATRICS. 

CASE 8. Robert R., the first child of healthy parents, had 
always been very well. He had been entirely breast-fed, had 
never had a cough and had not cried more than a normal baby 
should. When he was about three months old his mother 
noticed a bunch in the right groin. She had not seen it 
before, but could not say whether it had been there before or 
not. She thought that it had increased a little in size since 
she first discovered it. It apparently caused the baby no 
discomfort. He was seen in consultation a week after the 
discovery of the tumor. 

Physical Examination. He was in splendid general con- 
dition, large, fat and of good color. The fontanelle was level. 
There was no rosary. The heart, lungs and abdomen were 
normal. The liver was palpable 2 cm. below the costal border 
in the nipple line; the spleen was not palpable. The extremi- 
ties were normal. There was no spasm or paralysis; the 
knee-jerks were equal and normal; there was no Kernig's 
sign. There was no enlargement of the peripheral lymph 
nodes. 

There was a slightly elastic swelling, about the size and 
shape of a catbird's egg, in the right inguinal region just 
above the entrance to the scrotum. It was not tender, hot 
or red. It could be pushed upward and downward en masse, 
but could not be pushed into either the abdomen or the scro- 
tum. It did not gurgle. The inguinal rings felt alike on both 
sides, and nothing could be felt in them. Both testicles were 
in the scrotum. 

Diagnosis. The history is unimportant in this instance. 
Babies often develop an inguinal hernia without cough or 
excessive crying and the mother does not know whether the 
swelling was present at birth or appeared later. The diag- 
nosis must be made entirely on the physical examination. 
A partially descended testicle can be ruled out because both 
testicles are in the scrotum. The elasticity rules out a 
hyperplastic lymph node. It is, moreover, very unusual to 
find only one enlarged lymph node in the groin, and a large 
lymph node is seldom so movable. The normal condition of 
the inguinal ring rules out hernia. The absence of gurgling 
and the irreducibility of the mass are corroborative evidence 



DISEASES OF THE NEW-BORN. 3 1 

against hernia. The shape, elasticity, mobility and irreduci- 
bility are characteristic of an Encysted Hydrocele of the 
Cord, which is the diagnosis. 

Prognosis. There is, of course, nothing dangerous about 
this condition. A single tapping usually cures it. 

Treatment. The treatment is aspiration with a fine needle. 
One tapping will probably cure it. If it does not, the tapping 
may be repeated. An operation will almost certainly not be 
necessary. 



32 CASE HISTORIES IN PEDIATRICS. 

CASE 9. Roger S. was seen in consultation when three 
months old. He was the fifth child and was born at full 
term after a normal vertex labor. He was perfectly normal 
at birth, but when he was two days old it was noticed that 
he had some difficulty in breathing. This difficulty gradually 
increased for about three weeks, since when it had remained 
about the same. Inspiration was always noisy, whether he 
was awake or asleep. It was noisier when he was excited and 
when he was lying down, especially if he lay on his face. 
Expiration was quiet. He never became blue and never 
held his breath. His cry was always clear and he almost 
never coughed. He had at times a little difficulty in taking 
food. He was partly breast- and partly bottle-fed. His 
digestion had always been perfect and he had gained steadily 
in weight. 

Physical Examination. He was well developed and nour- 
ished, but a little flabby. He was somewhat pale, but not 
at all cyanotic. Inspiration was always accompanied by a 
crowing sound, which was more marked when he was fright- 
ened or excited. This noise was louder when he was lying 
down than when he was sitting up. He seemed uncomfortable 
when lying on his face. Expiration was perfectly quiet. 
His mouth was usually open, but the crowing sound was no 
louder and respiration was no more difficult when it was 
closed. His cry was perfectly clear. There was slight 
retraction of the epigastrium with almost every inspiration. 
This was more marked and was accompanied by marked 
retraction of the suprasternal and supraclavicular spaces 
when the crowing was louder. He was not at all cyanotic 
even when the crowing sound was the loudest. The anterior 
fontanelle was 4 cm. in diameter and level. The shape of the 
head was good. There was no craniotabes. The fauces, 
pharynx and nasopharynx showed nothing abnormal on 
either inspection or palpation. The thymic dullness was not 
increased and the thymus could not be felt in the suprasternal 
notch. The heart and lungs were normal. The chest was 
slightly flattened on the sides and the sternum was a little 
prominent. There was a moderate rosary. The abdomen 
was rather large, but otherwise normal. The lower border of 



DISEASES OF THE NEW-BORN. 33 

the liver was palpable 2 cm. below the costal border in the 
nipple line; the spleen was not palpable. The extremities 
showed nothing abnormal. There was no spasm or paralysis. 
The knee-jerks were equal, but not very lively. Kernig's 
sign was absent. There was no enlargement of the peripheral 
lymph nodes. Trousseau's sign and the facial phenomenon 
were absent. 

Diagnosis. Laryngismus stridulus can be excluded at 
once because the crowing sound is continuous. Other less 
important points against laryngismus stridulus are the early 
onset and the absence of other signs of increased nervous 
irritability (Trousseau's sign, facial phenomenon, exaggerated 
reflexes). Obstruction in the nose, nasopharynx and pharynx 
is excluded by the physical examination. Obstruction from 
pressure on the trachea by enlarged bronchial glands, new 
growths in the mediastinum or an enlarged thymus is ex- 
cluded by the fact that the interference is entirely with in- 
spiration. The sound resulting from obstruction in this 
locality is, moreover, not crowing in character. It cannot be 
due to obstruction within the larynx from inflammation or 
new growths, because the cry is clear and there is no cough. 
The obstruction must be, therefore, at the entrance of the 
larynx. The anatomical malformation which can produce 
this obstruction is a narrowing of the epiglottis with laxness 
of the ary-epiglottidean folds. This condition was found by 
laryngoscopic examination in this patient. The result of this 
condition, noisy inspiration, is known as Congenital 
Laryngeal Stridor. 

Prognosis. The prognosis is good, both as to life and 
recovery. The deformity disappears with the growth of the 
parts and the crowing gradually diminishes and finally ceases 
toward the end of the second year. 

Treatment. Nothing can be done to hasten the growth of 
the parts. It is important, however, to avoid, as far as 
possible, catarrhal processes in the respiratory tract. 



SECTION II. 
DISEASES OF THE GASTRO-ENTERIC TRACT. 

The classification which follows is a slight modification of 
that adopted by the Department of Pediatrics of the Harvard 
Medical School, and, while open to many objections, seems 
to the author more satisfactory than any other. It is given 
in order that the terms used later may be intelligible. 

The author is in the habit of roughly dividing the diseases 
of the gastro-enteric tract, associated with diarrhea, in the 
following manner. He realizes that this division is arbitrary 
and open to much criticism, but it seems to him reasonably 
satisfactory from a clinical standpoint and as a basis for 
treatment. 

When there is merely an increase in the number of move- 
ments, with a diminution in the consistency, no fever and 
practically no other symptoms, he describes the condition as 
nervous diarrhea and attributes it to causes acting directly 
or indirectly on the central nervous system. 

Under normal conditions there is an equilibrium between 
the work to be done and the power to do it, that is, between 
the food which is to be digested by the intestinal secretions 
and the secretions. If there is a disturbance of this equi- 
librium, either from an increase in the amount of work to be 
done, as occurs when the amount or strength of the food is too 
great, or from a diminution in the amount or digestive power 
of the secretions, as occurs when the child is depressed from 
any cause or is suffering from some other disease, the con- 
dition designated as intestinal indigestion due to disturb- 
ance of equilibrium develops. This condition may be 
either acute or chronic. Bacteria play no part in its 
etiology. The stools are increased in number and, as a 
rule, diminished in consistency, but usually not changed 
in color. They also show evidences of incomplete digestion 

35 



36 CASE HISTORIES IN PEDIATRICS. 

of the food. Under this head are included those disturbances 
due to an excess of one or more elements of the food, fat, 
carbohydrates or proteids, as the case may be. The character 
of the stools in such instances naturally varies according to 
what element or elements of the food are in excess. The 
term, malnutrition resulting from an excess of fat, carbo- 
hydrates or proteids in the food, describes the condition more 
satisfactorily, perhaps, than does that of chronic intestinal 
indigestion. 

If fermentation or decomposition takes place in the in- 
testinal contents as the result of bacterial action, new symp- 
toms develop. The stools are usually changed in color and 
odor and show more marked disturbance of digestion. Other 
symptoms, such as fever, may appear as the result of toxic 
absorption. This is the class of cases known as intestinal 
indigestion of the fermentative type. It is more often acute 
than chronic. It is assumed that in pure cases there is no 
inflammation of the intestine and no entrance of bacteria 
into the circulation. 

If the bacteria cause inflammatory changes in the intestinal 
wall there is usually a further change in the character of the 
stools, which become very numerous and are composed 
mainly of mucus and blood. The temperature is usually 
moderately and constantly elevated, and the constitutional 
symptoms are much more marked. It is probable that in 
many instances bacteria traverse the intestinal wall and enter 
the circulation. This condition is called infectious diarrhea 
of the dysenteric type. 

Cholera infantum, in which there is a very large number 
of profuse watery movements, is presumably a variety of 
infectious diarrhea. 

Since the diagnosis between the various diseases of the 
gastro-enteric tract is of relatively more importance than 
that between these and other diseases, the cases illustrative of 
them are given together and follow. 



DISEASES OF GASTRO-ENTERIC TRACT. 



37 



Gastric. 

Developmental Malpositions. 

Malformations — Pyloric stenosis. 

Non- Infectious Functional. 

Nervous vomiting. 

Recurrent vomiting. 

T ,. . ( Acute. 
Indigestion j chronia 

Mechanical. 

Contraction. 

Dilatation. 
Ulcers — peptic. 
New growths. 
Gastritis — corrosive. 
Infectious Gastritis. 

Enteric. 

Developmental Malpositions. 

Malformations. 

Non- Infectious Mechanical. 

Dilatation of colon. 

Volvulus. 

Intussusception. 

Hernia. 

Fissure. 

Prolapse. 

Polypi. 

Hemorrhoids. 

New growths. 

Functional. 

Incontinence. 

( Atonic. 

Constipation ■{ Spasmodic. 

^Mechanical. 

Nervous diarrhea. 

Indigestion 

Acute. 

Chronic. 

f Disturbance ( Acute. 

Intestinal^ of equilibrium ( Chronic. 

'^Fermentation. 

Infectious Proctitis. 

Appendicitis. 

Fistulae. 

T r . ,. , ( Dysenteric type. 
Infectious diarrhea j c £ olera infa ^ um . 

Animal Parasites. 



Duodenal 



38 CASE HISTORIES IN PEDIATRICS. 

CASE io. Robert M., the second child of healthy parents, 
was born at full term after a normal labor. He was normal at 
birth and weighed six pounds and twelve ounces. His mother 
had a plentiful supply of milk and he was nursed regularly at 
two-hour intervals. He vomited a little from the first, but 
when two weeks old began to vomit much more. This was 
at first attributed to indiscretions in diet on his mother's 
part, but continued to increase after her diet was carefully 
regulated. It was then thought that he got too much milk, 
and the length of nursing was shortened to five minutes. 
This made no difference in the vomiting. A half-teaspoonful 
of lime water was then given with each nursing, but did not 
affect the vomiting. The mother was a healthy, vigorous 
woman, and it did not seem probable that the composition 
of the breast-milk was at fault, although it had not been 
examined. Whey, which was tried for twenty-four hours, 
was vomited more than the breast-milk. The vomiting some- 
times occurred immediately after nursing, but usually not for 
an hour or more. Sometimes several feedings were retained 
and then vomited together. The vomiting had recently been 
explosive. The bowels had moved regularly, but the move- 
ments had been small ; they were dark green in color and 
composed largely of mucus with a few fine curds. He acted 
hungry all the time and cried a great deal, apparently from 
hunger. He gained slowly in weight during the first three 
weeks up to seven pounds and twelve ounces. When seen in 
consultation, when five weeks old, he had dropped back to 
seven pounds and four ounces. 

Physical Examination. He was well developed .and nour- 
ished and of good color. The fontanelle was level, and the 
bones of the skull did not overlap. His tongue was clean and 
moist. The heart and lungs were normal. The liver was 
palpable i cm. below the costal border in the nipple line. 
The spleen was not palpable. The extremities were normal. 
There was no spasm or paralysis; the knee-jerks were equal 
and normal. There was no enlargement of the peripheral 
lymph nodes. The examination of the abdomen was at first 
rather difficult because of the crying, and nothing abnormal 
was detected. The stomach was undoubtedly empty, as he 



DISEASES OF GASTRO-ENTERIC TRACT. 39 

had vomited a great deal about an hour before and had taken 
nothing since. It was thought that he would keep quieter if 
his stomach was filled and that perhaps something might be 
seen or felt then which could not be before. He was, there- 
fore, given two and one-half ounces of water, which he took 
greedily. The lower border of the stomach then reached to 
the navel, and very marked waves of peristalsis, running from 
left to right, appeared. A mass about the size of a marble was 
felt indistinctly in the region of the pylorus. He then vomited 
the whole of the water in one gush, the water striking the floor 
about three feet from the baby. The tumor could then be 
felt very distinctly while the baby was relaxed after the vomit- 
ing. He had a small movement, consisting of about half a 
teaspoonful of brownish mucus, during the examination. 

Diagnosis. The history in this instance is so typical of 
Infantile Pyloric Stenosis that it justifies, as far as any 
history without physical examination can, a positive diagnosis 
of this condition. The only other disease to be seriously 
considered is chronic gastric indigestion. The appearance of 
vomiting in a breast-fed baby after two weeks, in which there 
had been only a little spitting up, the progressive increase of 
the vomiting, the failure to respond to regulation of the 
nursing, the explosive character of the vomiting and the small 
meconium-like stools containing almost no fecal residue, are 
not consistent with chronic gastric indigestion. A cerebral 
lesion as the cause of the vomiting can be immediately ruled 
out on the general condition, the level fontanelle and the 
absence of spasm, paralysis and increased reflexes. 

The physical examination verifies, of course, the diagnosis 
made on the history. The enlargement of the stomach, the 
visible peristalsis and the palpable tumor are proof positive. 
The methods employed in the examination of the abdomen 
are worthy of attention. No examination of the abdomen 
can be considered complete, when there is a suspicion of 
stenosis of the pylorus, unless it is made with the stomach 
both full and empty. If peristalsis is not visible when the 
stomach is full, it can often be produced by stroking the 
epigastrium or flicking it with a towel wet in cold water, or a 
piece of ice. The author believes that a positive diagnosis of 



40 CASE HISTORIES IN PEDIATRICS. 

pyloric stenosis would have been justified in this case even if 
a tumor had not been felt. 

Prognosis. The prognosis without operation is hopeless; 
with an operation by a competent surgeon the outlook is 
very good, because of the baby's good general condition. 
The operations for this condition are all so recent that there 
are almost no data as to what happens to these babies in 
after years. What data there are, however, go to show that 
their digestive powers are not impaired, that they develop 
normally and that their expectation of life is not altered. 

Treatment. The only rational treatment in this instance 
is immediate operation. The best operation is a posterior 
gastro-enterostomy. It is a delicate operation, requiring 
special skill. Slight variations in technic make the difference 
between success and failure, life and death. No surgeon 
who has not done it before, or who has not had much experi- 
ence in operating on small animals, should attempt it. 



DISEASES OF GASTROENTERIC TRACT. 4 1 

CASE 11. Mary M., three and a half years old, was in 
the habit of having occasional attacks of vomiting, which 
were usually of short duration. She was a well and vigorous 
but nervous child. She was carefully fed. July i she ate 
an unusually hearty supper of proper food at six o'clock and 
then played very hard and was a good deal excited for about 
half an hour. She went to bed soon after and quickly dropped 
to sleep. She woke up and began to vomit at 9 p.m. The vom- 
iting continued and finally there was much retching without 
vomiting. The vomitus at first consisted of the food taken at 
supper, later of nothing but mucus. She was seen at 1 1 .30 p.m. 

Physical Examination. She was well developed and nour- 
ished and did not look or act ill. Her tongue was nearly 
clean. The level of the abdomen was that of the thorax. 
There was no muscular spasm or tenderness. The rest of a 
careful physical examination showed nothing abnormal. 
The rectal temperature was 98. 6° F. 

Diagnosis. The absence of physical signs and the normal 
temperature rule out at once all diseases outside of the diges- 
tive tract. The only diseases of this tract to be considered 
are nervous vomiting, acute gastric indigestion and the onset 
of recurrent vomiting. 

It is impossible to absolutely exclude recurrent vomiting 
at this time, only two and a half hours after the onset, but 
the history of similar attacks in the past, all of short duration, 
makes it very improbable. The differentiation between 
nervous vomiting and acute gastric indigestion is a rather 
difficult and uncertain one, as the line between the two forms 
is not very sharp. The absence of temperature and the prac- 
tically normal condition of the tongue are against indigestion. 
The fact that the vomiting developed after a meal of proper 
food followed by undue exertion and excitement point strongly 
to a nervous disturbance. The over-exertion and excitement 
presumably inhibited digestion, and the undigested food 
acted like a foreign body in the stomach and brought on the 
vomiting by reflex action. The diagnosis is, therefore, Nerv- 
ous Vomiting. 

Prognosis. The prognosis as to life is, of course, good. 
The stomach having been thoroughly emptied, as shown by 



42 CASE HISTORIES IN PEDIATRICS. 

the character of the last vomitus, the vomiting ought to 
stop in a few hours or less, if nothing is done in the way of 
medication to keep it up. 

Treatment. Quiet and frequent sips of a solution of bi- 
carbonate of soda, fifteen grains to a glass of water, are all 
that is necessary. A mild laxative, such as two teaspoonfuls 
of milk of magnesia, in the morning, to hurry along any undi- 
gested food which may have passed into the intestine is 
advisable. Broth and toast for breakfast, and a rather light 
diet and quiet for the rest of the next day, complete the 
treatment. 



DISEASES OF GASTRO-ENTERIC TRACT. 43 

CASE 12. Rosamond B. was seven and a half years old. 
Her mother had valvular heart disease and was markedly 
neurotic. Her mother's family was extremely neurotic and 
several members had been insane. Her father's family was 
rheumatic. 

She was a decidedly neurotic child and was very fussy 
about her diet, and had also been fed very carefully because of 
the rheumatic family history. Her appetite was very good. 
She had had no symptoms of indigestion except that her 
bowels were always constipated. She had been taking cascara 
regularly for more than a year. 

She had had no unusual excitement, had not exerted her- 
self unduly, and had done nothing unusual during November 
28. She began to vomit at 5 a.m., November 29. She vomited 
every few minutes during that day and night and about 
every two hours during the 30th up to 9 p.m., when she was 
seen in consultation. In all, she vomited fifty- two times 
during this period. The vomiting was not explosive. The 
vomitus at first contained a little of the food taken at supper, 
but after this consisted of water mixed with a little mucus. 
It did not contain bile. She had taken nothing by mouth 
except water in small quantities and cracked ice, which had 
been given because of the extreme thirst. Both had been 
vomited immediately. The bowels had been moved freely 
by enemata. The stools were normal in character. Her 
temperature, taken in the axilla, had ranged between 99 F. 
and ioo° F. She had been rather restless and had slept 
but little. Bromide, given by enema, had quieted her 
considerably. She had had no pain. 

Physical Examination. She was tall and slight. Her color 
was good. The pupils were equal and reacted to both light 
and accommodation. There was no rigidity of the neck. 
She was perfectly clear mentally. Her tongue was moist 
and but slightly coated. Her breath had a slightly sweetish^ 
odor. The heart, lungs and liver were normal. The level of 
the abdomen was that of the thorax. There was no muscular 
spasm and no tenderness. Palpation was easy and disclosed 
nothing abnormal. The spleen was not palpable; the area 
of dullness was normal. The extremities showed nothing 



44 CASE HISTORIES IN PEDIATRICS. 

abnormal. There was no spasm or paralysis. The knee- 
jerks were equal and lively. Kernig's and Babinski's signs 
were both absent. The cervical and axillary lymph nodes 
were somewhat enlarged; the inguinal were not. The 
rectal temperature was 99 F., the pulse 96, the respiration 
20. She did not object to the examination, but gave the 
impression that she was decidedly neurotic. 

The urine contained neither albumin nor sugar, but gave 
the tests for both acetone and diacetic acid. 

Diagnosis. The conditions which may be reasonably 
considered in this instance are meningitis, more likely tuber- 
cular than cerebrospinal, intestinal obstruction, nervous 
vomiting and recurrent vomiting. 

Meningitis can be at once excluded on the combination of 
the absence of all signs of meningeal irritation, the low tem- 
perature and the excessive amount of the vomiting compared 
with the other symptoms. It can be so positively excluded 
that lumbar puncture is not justified as a method of diagnosis, 
although this ought to be done in every case in which there is 
a reasonable chance of meningitis because of the good which 
can be accomplished by the serum treatment in cerebrospinal 
meningitis, especially when the diagnosis is made early. 

Intestinal obstruction can also be excluded on the char- 
acter of the vomitus, the absence of physical signs in the 
abdomen, the clean tongue, the free movements from the 
bowels, the low temperature and the good general condition. 

The neurotic family history and the neurotic disposition 
of the patient are consistent with either nervous or recurrent 
vomiting. So are the character of the vomitus, the absence 
of physical signs, the clean tongue, the low temperature and 
the good general condition. The excessive amount of the 
vomiting and the absence of any cause for nervous vomiting 
make this diagnosis very improbable. In fact, the whole 
picture is characteristic of what is known as Recurrent 
Vomiting. It may be said that it is incorrect to call the 
condition " recurrent vomiting " when the child has never 
had anything like it before. It must be remembered in this 
connection, however, that there is always a first time for 
everything. Since acid intoxication is probably one of the 



DISEASES OF GASTRO-ENTERIC TRACT. 45 

causes of recurrent vomiting, the sweet odor of the breath and 
the presence of acetone and diacetic acid in the urine might 
be thought indicative of this condition as against nervous 
vomiting. This is not so, however, as the abstinence from 
food for thirty-six hours will account for them equally well. 

Prognosis. There is no danger as to life. The vomiting 
will probably not persist more than forty-eight hours longer, 
more likely a shorter than a longer time. The duration will 
depend somewhat on whether the treatment is rational or 
not. 

Treatment. Before taking up the treatment it must be 
remembered that recurrent vomiting is probably merely a 
symptom-complex of manifold etiology. In most instances it 
is a manifestation of some disturbance of metabolism. This 
disturbance is sometimes an intoxication from the acetone 
bodies (the so-called acid intoxication) and sometimes an 
intoxication from uric acid. Most often the nature of the 
disturbance is unknown. In some instances it is a manifesta- 
tion of inflammation of the appendix. In this instance ap- 
pendicitis can be immediately ruled out on the absence of all 
signs of inflammation in this region. It is impossible to state, 
however, what the nature of the disturbance of metabolism 
is. The sweet breath and the presence of acetone bodies in 
the urine suggest acid intoxication. They do not prove it, 
however, because starvation will also account for them. It 
is reasonable, however, to treat the condition on this basis. 
Such treatment can do no harm if it does no good. 

This treatment consists in the administration of bicarbon- 
ate of soda. From one-half ounce to an ounce should be given 
in twenty-four hours. The attempt should be made to give 
it by mouth in teaspoonful or tablespoonful doses of a solu- 
tion of bicarbonate of soda, one teaspoonful to a glass of water, 
every fifteen to thirty minutes. It is well to persist, even if 
the soda is vomited. High enemata of a solution of bicarbon- 
ate of soda, two drams to six ounces of water, should be 
given every four hours. The child should be kept perfectly 
quiet, in a cool, dark room. No food should be given by 
mouth. It will probably be necessary on account of the 
excessive thirst to give small amounts of liquid, even if vom- 



46 CASE HISTORIES IN PEDIATRICS. 

ited. Water or carbonated water, in doses of from one tea- 
spoonful to one tablespoonful, or cracked ice, may be given. 
If she is restless or sleepless from vomiting, ten or fifteen 
grains of bromide of soda may be given in the enemata of 
bicarbonate of soda. If this is not effective, morphia, gr. ^g, 
may be given subcutaneously. Food should not be given 
until twelve hours after the vomiting has stopped. Whey, 
cereal waters, or cereal waters with sugar, should then be 
given, beginning with an ounce every hour and increasing 
the amount if they are retained. These foods are given in- 
stead of broths or albumin water because the carbohydrates 
antagonize the acid intoxication and have more food 
value. 



DISEASES OF GASTRO-ENTERIC TRACT. 47 

CASE 13. Ralph C, two years old, had always been well 
except for an occasional attack of acute gastric or intestinal 
indigestion. He had had nothing unusual for supper, but had 
eaten a good deal hurriedly and had been a good deal excited 
after supper. He began to vomit and to be feverish about 
midnight. The vomitus consisted first of his supper and then 
of water and mucus. He had apparently had no pain, and 
had been clear mentally. The bowels had not moved. He 
had no cough. He was seen at 5 a.m. 

Physical Examination. He was well developed and nour- 
ished, but a little pale. He vomited twice during the examina- 
tion. He was perfrectly clear mentally. There was no motion 
of the alae nasi and the respiration was quiet. There was no 
rigidity of the neck. The pupils were equal and reacted to 
light. The tongue was moist, moderately coated and not 
reddened. The throat was normal. The heart and lungs 
were normal. The abdomen was a little sunken and lax. 
There was no tenderness, muscular spasm, tumor or dullness. 
The liver was just palpable, the spleen was not. The extremi- 
ties were normal. There was no spasm or paralysis. The 
knee-jerks were equal and normal; Kernig's sign and the neck 
sign were absent. There was no rash. The membranae 
tympanorum were normal. The rectal temperature was 
103. 5° F., the pulse 130, the respiration 30. 

Diagnosis. The sudden appearance of vomiting and fever 
is consistent at this age with the onset of almost any acute 
disease, and it is often impossible as early as this to make a 
positive diagnosis. Certain diseases are more probable, 
however, than others. These are, in the first place, acute 
gastric indigestion, pneumonia and scarlet fever; in the sec- 
ond place, tonsillitis, influenza, otitis media and meningitis, 
especially of the cerebrospinal form. 

The normal ear drums rule out otitis media; the absence 
of reddening of the throat and enlargement of the tonsils, 
tonsillitis. Meningitis, beginning with such acute symptoms 
as in this instance, would almost certainly have shown by 
this time some signs of meningeal irritation, none of which 
are present. The relatively slow rate of the respiration in 
comparison with the pulse practically rules out pneumonia. 



48 CASE HISTORIES IN PEDIATRICS. 

The absence of cough, of motion of the alse nasi and of 
physical signs in the lungs, together with the quiet respira- 
tion, are also against it, but not nearly as important as the 
relatively low rate of the respiration. The absence of inflam- 
mation of the throat and enlargement of the papillae of the 
tongue is against scarlet fever, but does not rule it out, as> 
they might not have developed at this time. The rash would 
not, of course, have appeared thus early. Scarlet fever is, 
therefore, a possibility. Influenza is always a possibility 
with this history, as its manifestations are so manifold. 
The abdominal type is, however, much less common at this 
age than the respiratory type. The history of attacks of 
acute gastric indigestion in the past, the hurried and hearty 
supper with the subsequent excitement, the absence of the 
signs characteristic of other diseases and the fact that acute 
gastric indigestion is very common while the other conditions 
to be considered are relatively rare, make the diagnosis 
of acute gastric indigestion altogether the most probable. 
The final diagnosis is, therefore, Acute Gastric Indigestion, 
with the bare possibility that it may be scarlet fever or 
influenza. Twenty-four, or at most forty-eight hours, will 
settle the diagnosis positively, either by the cessation of the 
symptoms or the development of something more definite. 

Prognosis. The prognosis as to life is, of course, absolutely 
good. The vomiting will probably cease during the day. 
He will, however, probably have more attacks unless his diet 
and routine are very carefully regulated. 

Treatment. The treatment should be on the basis of the 
diagnosis of acute gastric indigestion. It will do no harm 
if the true diagnosis proves to be scarlet fever or influenza. 
The first thing to do is to cleanse the stomach. The quickest 
and most effective way to do this is to wash out the stomach. 
This is a very simple operation in a child of this age. A soft 
rubber catheter, No. 16 American, is used. It should be 
passed through the mouth and the stomach washed with 
plain water, or a weak solution of bicarbonate of soda, until 
the wash water returns clear. The stomach may also be 
cleansed, but less quickly and effectually, by giving copious 
drinks of water which will probably be immediately vomited. 



DISEASES OF GASTRO-ENTERIC TRACT. 49 

Food should be entirely withheld for from eight to twelve 
hours. Whey or broth, in one or two-ounce doses, every one 
or two hours, may then be given. A solution of bicarbonate 
of soda, one-half teaspoonful to a glass of water, given in 
teaspoonful doses every fifteen to thirty minutes, will prob- 
ably help to quiet the stomach. 

After the stomach has been cleansed and rested for an hour 
or two, a dessertspoonful of castor oil should be given. This 
may be vomited, but will probably be retained. If it is 
vomited, one-half teaspoonful doses of milk of magnesia, 
given at hour intervals, until three teaspoonfuls have been 
given, will probably be retained. 

Sponge baths of 95% alcohol and water, equal parts, at 
90 F., will reduce the fever and make the child more com- 
fortable. 



50 CASE HISTORIES IN PEDIATRICS. 

CASE 14. Robert M. was the first child of healthy par- 
ents. He was born at full term after a normal labor, and 
weighed six pounds and ten ounces. He was nursed entirely 
for a month, digested well, and went up to seven pounds and 
fourteen ounces. The breast-milk then began to diminish 
and was helped out by a home-modified milk which contained 
3-5°% of fat, 6.00% of sugar and 0.70% of proteids. The 
baby soon began to have the colic and lose weight, while the 
stools contained large tough curds, showing casein indigestion. 
The breast-milk then gave out entirely and he was given a 
milk mixture prepared with Eskay's Food, which contained 
3% of fat, 3.50% of sugar, 0.75% of proteids and 2% of 
starch, alternating with barley water, containing 1.50% of 
starch. Possibly because of the starch in the Eskay's Food 
and barley water he ceased to pass the large tough curds, but 
began to vomit and to lose weight steadily. When two 
months old he was taken to a hospital, where he remained 
until he was five months old. While there he was fed on 
various milk mixtures and improved somewhat. He con- 
tinued to vomit, however. His weight on leaving the hospital 
was eight pounds and twelve ounces. He was then put on a 
modified milk of unknown composition prepared with Mellin's 
Food. This, of course, practically amounts merely to the 
substitution of malt sugar for milk sugar in the milk mixture. 
He gained at first to nine pounds, but soon began to refuse 
his food, vomit and lose weight again. 'He was then given a 
mixture of one-third gravity cream and two-thirds barley 
water, which is equal to a mixture containing 5% or more of 
fat, 1.50% of sugar, 1.15% of proteids and 1.00% of starch. 
He gained again for a time, but soon began to vomit more 
than before. A malted milk mixture was then given. This, 
like the Mellin's Food mixture, amounted to little more than 
giving malt sugar in place of milk sugar. He kept this down 
and gained for a time, but soon began to vomit worse than 
ever. The doctor then said that the baby " could not take 
cow's milk," and put him on Allenbury's Food No. 1, pre- 
pared according to directions. This was about a week before 
he was seen. The composition of the mixture was, according 
to the proprietor's figures, 3.33% of fat, 10.20% of lactose, 



DISEASES OF GASTRO-ENTERIC TRACT. 5 1 

1.00% of albumin and 1.12% of casein. He had a great deal 
of gas after beginning this and continued to vomit. The 
bowels, which had been somewhat constipated, became loose, 
and the movements, which had been of good character, were 
undigested and contained a good deal of mucus. He was 
taking seven or eight feedings of from four to four and one- 
half ounces of the Allenbury's Food mixture, at two and one- 
half-hour intervals, when he was seen in consultation, when 
seven months old. 

Physical Examination. He was bright and happy. He was 
small and poorly nourished, but of good color. The skin was 
in good condition. The fontanelle was 3 cm. in diameter and 
level. There was no rigidity of the neck. He had no teeth. 
The mouth, tongue and throat were normal. The heart and 
lungs were normal. The abdomen was large but not tense. 
The liver was palpable 3 cm. below the costal border in the 
nipple line. The spleen was not palpable. The lower border 
of the stomach did not reach to the navel. The stomach was 
not visible even after taking his bottle, and there was no 
visible peristalsis. The abdomen was negative. There was 
a small umbilical hernia. The extremities were normal. 
There was no spasm or paralysis; the knee-jerks were equal 
and lively; Kernig's sign was absent. There was no enlarge- 
ment of the peripheral lymph nodes. The weight Avas nine 
pounds and four ounces. 

Diagnosis. The physical examination shows nothing ab- 
normal except the signs of malnutrition. The diagnosis must 
be made, therefore, on the history. The continued vomiting 
shows that the gastric digestion was disturbed. The normal 
character of the movements up to the last change in the food 
shows that the intestinal digestion was not affected until the 
very end. The tendency to constipation was presumably due 
to the facts that much of the food was vomited and that the 
portion which passed into the intestine was so small that 
little residue was left to form feces. The diagnosis is, there- 
fore, Chronic Gastric Indigestion. 

It is very difficult in this instance to draw any very definite 
conclusions as to what element or elements of the food were 
at fault. In general, the percentages of the fat were not 



52 CASE HISTORIES IN PEDIATRICS. 

excessive, most of the time being below 3.50% and only once 
above 4%. The proteids were usually both absolutely and 
relatively high. The sugars were at times excessive, espe- 
cially in the last mixture, which contained over 10% of lactose. 
The increase in the amount of gas at this time and the change 
for the worse in the character of the movements suggest that 
sugar was not well borne. The food at times contained more 
starch than many babies of this age can digest. The symp- 
toms were no more marked at such times, however, than they 
were when there was no starch in the food. The only con- 
clusions which can be drawn are that the baby is unable to 
digest large amounts of sugar, and, by exclusion, that the 
somewhat excessive amounts of starch in the food may pos- 
sibly have played a part in the production of the trouble. 

Prognosis. Chronic gastric indigestion is always a serious 
condition, one never to be regarded lightly. In this instance, 
however, the comparative mildness of the symptoms and the 
baby's reasonably good condition justify, barring accidents, 
a favorable prognosis. 

Treatment. The best food for this baby, as for all babies 
suffering from chronic gastric indigestion, is good human 
milk. With it recovery is certain to be rapid. It is not a 
necessity in this instance, however, and the baby will prob- 
ably recover in time without it. The best substitute for it is 
some modification of cow's milk. A doctor has said, however, 
that this baby " can't take cow's milk." Is this statement 
true in this instance, or is it ever true? The author believes 
that it is extremely unusual for a baby to be born with an 
idiosyncrasy against cow's milk. He also believes that the 
improper use of cow's milk may develop a temporary, but not 
a permanent, intolerance for cow's milk. There is nothing in 
this baby's history, however, to show that it cannot digest 
cow's milk, if properly modified to suit its digestive capacity, 
most of the modifications which it has had in the past having 
been unsuitable in some way or other. 

The only definite indications to be drawn from the history 
of this baby as to the regulation of the food are to keep the 
sugar comparatively low and not to give starch. On general 
principles, it is advisable to keep the fat a little low when 



DISEASES OF GASTRO-ENTERIC TRACT. 53 

babies are vomiting. It is wiser, therefore, not to give this 
baby more than 2% of fat at first. In chronic gastric indi- 
gestion the food should, if possible, be so regulated as to 
diminish the work of the stomach and throw it on the intestine. 
The addition of an alkali to the food retards the coagulation 
of casein by rennin and allows the liquid milk to pass into the 
intestine, thus throwing the work of digestion from the stom- 
ach on to the intestine. If the lime water, the alkali most 
often used, is equal to 50% of the milk and cream in the mix- 
ture, it practically prevents the coagulation of the casein and 
throws all the work on the intestine. If the lime water is 
2 5% of the milk and cream, it throws a proportionate part of 
the work on the intestine, and so on. It is evident that as the 
important relation is between the casein and the lime water, 
and as the milk and cream are the only substances in the 
mixture containing casein, the amount of lime water to be 
added must be calculated in relation to the milk and cream 
and not in relation to the total quantity of the mixture, which 
is made up largely of water, or to whey, which contains no 
casein. Lime water is indicated in this instance, therefore, 
and in the proportion of 25% of the milk and cream in the 
mixture. Whey proteids are not acted on by rennin, leave 
the stomach quickly and throw but little work upon it. They 
are, therefore, indicated in this instance. The following 
formula meets these indications: 

Fat, 2.00% 

Milk sugar, _ 5-50% 
Whey proteids, 0.75% 
Casein, 0.25% 

Lime water, 25.00% of the milk and cream. 

Four ounces is as much as he should have at a feeding. 
Eight feedings, at two and one-half hour intervals, gives 
103 calories per kilo, and 2.3 grams of proteid per kilo, which 
covers both the caloric and proteid needs. 

If whey mixtures are not satisfactory, pancreatization of 
suitable milk and cream mixtures may be tried. 

No drugs are indicated. The symptoms at present are 
hardly severe enough to require lavage. 



54 CASE HISTORIES IN PEDIATRICS. 

CASE 15. Mary D., five and one-half months old, had 
always been a perfectly well, breast-fed baby. About 6 a.m., 
September 6, she suddenly began to cry and to put her hands 
on her abdomen. The crying continued for half an hour or 
more. At about this time she had three movements con- 
sisting almost entirely of bright blood. After this she vomited 
two or three times. The character of the vomitus was not 
noticed. Judging from the story, she evidently was somewhat 
collapsed for a short time after the onset of the pain. She 
was seen about 7.30 a.m. by her physician, who examined the 
abdomen but found nothing abnormal. He did not consider 
the condition an important one, although he watched the 
case very carefully afterward. She continued to have seven 
or eight small movements daily, which consisted entirely of 
mucus and blood. The amount of blood, however, had 
steadily diminished. The movements contained no fecal 
matter. A bismuth mixture, which was ordered at the first 
visit, was vomited. There was no more vomiting until the 
noon of the 8th, since when she had vomited almost con- 
stantly. She continued to take the breast well. She had had 
no very sharp attacks of pain, but had slept very little, moan- 
ing most of the time. She did not seem very sick until the 
8th and had noticed things and played a little that afternoon. 
The temperature had been taken morning and evening, but 
had never been over ioo° F. The mother thought that she 
felt a bunch in the abdomen the evening of the 7th, but both 
the mother and the doctor failed to find it the next morning. 
She was given two teaspoonfuls of castor oil the morning of 
the 8th, which were vomited, and also several large injections 
of salt and water, which brought away nothing but mucus and 
blood. She was seen in consultation at 9 p.m., September 8, 
sixty-three hours after the onset. 

Physical Examination. She was well developed and nour- 
ished. There was slight pallor. Her face was drawn and 
anxious. She noticed a little. The fontanelle was nearly 
level. The tongue was slightly dry, but not coated. The 
heart and lungs showed nothing abnormal. The liver was 
palpable 3 cm. below the costal border in the nipple line. 
The spleen was not palpable. The level of the abdomen was 



DISEASES OF GASTROENTERIC TRACT. 55 

somewhat below that of the thorax. An indefinite resistance 
was felt in the left lower quadrant. There was no muscular 
spasm, but a little tenderness in this region. The rest of the 
abdomen was negative. Rectal examination showed more 
resistance in the left half of the abdomen than in the right, 
but nothing at all definite. The extremities showed nothing 
abnormal. There was no enlargement of the peripheral 
lymph nodes. The rectal temperature was 100.4 F., the 
pulse 180. 

Diagnosis. The diagnosis of Intussusception is so plain 
in this instance that it is hard to understand how it could 
have been mistaken for infectious diarrhea, as was done. 
The sudden onset of severe abdominal pain with partial 
collapse, the vomiting and the passage of bright blood are 
pathognomonic of intussusception and entirely different 
from the slow onset of infectious diarrhea. The further 
course of the disease, with continued abdominal pain and 
numerous stools of mucus and blood without fecal matter, is 
most characteristic. Pain is uncommon, except at the time 
of defecation, in infectious diarrhea at this age, and some of 
the movements always contain fecal matter. The physician 
was undoubtedly misled by the facts that the baby nursed 
well and did not appear very ill. It is, however, not at all 
uncommon for babies with intussusception to take their food 
well almost to the end, and the general condition is often not 
much affected during the first thirty-six hours or so. He was 
also probably further misled by the moderate temperature. 
This, again, is characteristic of intussusception, high fever 
being very unusual. He should have paid more attention to 
the mother's story of a bunch in the abdomen and not have 
trusted so much to his own negative examination, for it often 
happens that the tumor can be felt at one time and not at 
another. The failure to obtain fecal matter from the injec- 
tions should also have suggested intussusception. The castor 
oil was, of course, very bad treatment. If it had been re- 
tained, it would have merely made the intussusception 
tighter. 

The physical examination, as often happens in intussuscep- 
tion, aids but little in the diagnosis. The strained and anxious 



56 CASE HISTORIES IN PEDIATRICS. 

face are suggestive of intussusception, but not inconsistent 
with infectious diarrhea. The indefinite resistance and slight 
tenderness in the left lower quadrant and the increased 
resistance in the left half of the abdomen on rectal examina- 
tion are corroborative of the diagnosis of intussusception, but 
without the history would not be of much importance. 

Prognosis. The prognosis is very grave. It is almost 
certain that during the sixty-three hours since the onset ad- 
hesions have formed so that the intussusception cannot be 
reduced. The circulation has been interfered with so long 
that the gut is almost certainly gangrenous. A resection will 
undoubtedly have to be done. There is not one chance in 
ten for recovery. 

Treatment. The only possible treatment is immediate 
operation. 



DISEASES OF GASTRO-ENTERIC TRACT. 57 

CASE 1 6. Sophie M., nine months old, was the child of 
healthy parents. She was born at full term after a normal 
delivery and had always been well. She had been nursed 
irregularly, but had had no other food except occasionally a 
little zwiebach. 

She woke up from a nap crying, evidently from pain in the 
abdomen, about noon, April n. She was pale for some time 
after she ceased crying. She had nursed well since then but 
had vomited everything taken, including a number of cathar- 
tics, almost immediately. The vomitus consisted of the food 
taken, with a little water and mucus ; it was never greenish or 
brownish. She had had no fecal movement of the bowels, 
although numerous enemata had been given. Once she had 
passed " a small glassful of clear blood." She had apparently 
not been much feverish and had apparently not had any pain 
since the onset. She had passed very little urine. She was 
seen at noon, April 13, forty-eight hours after the onset. 

Physical Examination. She was well developed and nour- 
ished and a little pale. She was moderately prostrated, but 
her face was not pinched and her eyes were clear. The an- 
terior fontanelle was slightly depressed. The pupils were 
equal and reacted to light. There was no rigidity of the neck 
or neck-sign. The tongue was rather dry, but not red or 
coated. The throat was normal. The heart and lungs were 
normal. There was no rosary. The liver was just palpable. 
The spleen was not palpable. The level of the abdomen was 
a little below that of the thorax. There was no definite 
muscular spasm, but the whole abdomen was held a little 
rigidly, especially in the right lower quadrant. There was 
no tenderness or dullness. Nothing at all definite could be 
made out in the right lower quadrant, but it seemed as if 
there was a little more resistance there than on the other side. 
Rectal examination showed nothing abnormal. The rectum 
was empty. There was no blood on the examining finger. 
The extremities were normal. There was no spasm or pa- 
ralysis; the knee-jerks were equal and normal; there was no 
Kernig's sign. 

There was no enlargement of the peripheral lymph nodes. 
The rectal temperature was 98. 6° F., the pulse 136. 



58 CASE HISTORIES IN PEDIATRICS. 

Diagnosis. The diagnosis in this instance lies between 
acute gastric indigestion, with secondary constipation, and 
intussusception. The points in favor of intussusception are 
the sudden onset in a breast-fed baby, the continued vomiting, 
the absence of fecal movements, the history of the movement 
of blood, and the slight rigidity and sense of resistance in the 
right lower abdomen. The points against intussusception are 
the character of the vomitus, the slight amount of prostration, 
the absence of an abdominal tumor, the negative rectal exami- 
nation and the low temperature. It may also be argued 
that the history of the passage of "a small glassful of clear 
blood " was probably untrue, and that if the baby had passed 
blood once it would certainly have passed it again if the con- 
dition was intussusception. The small amount of urine is, of 
course, of no importance, merely meaning that very little 
fluid was retained. 

There is no question as to the validity of the objections 
to the diagnosis of intussusception. They are, however, all 
unimportant compared with the almost pathognomonic com- 
bination of the sudden onset of abdominal pain in a breast-fed 
infant, the constant vomiting, the obstipation and the passage 
of blood. These are positive symptoms ; the others are merely 
negative. The absence of fecal vomiting can be explained 
on the ground that the reverse peristalsis is not very active; 
the absence of frequent movements of blood and mucus, on 
the ground that the constriction is not very tight, and that 
consequently there is not much congestion or exudation into 
the bowel, and not much peristalsis set up. The absence of a 
tumor can be explained by the absence of a very tight con- 
striction or of marked swelling, or by the deep location of the 
tumor; the absence of a tumor on rectal examination, by the 
high position of the intussusception; and the low tempera- 
ture by the absence of absorption. 

These signs are so characteristic of Intussusception that it 
is hardly necessary to attempt to rule out other forms of intes- 
tinal obstruction. Some other form is, however, a possibility. 
Fortunately, the treatment is the same in any instance. 

Prognosis. The chances for recovery are about even in this 
instance, with a good surgeon, if operation is done at once. 



DISEASES OF GASTRO-ENTERIC TRACT. 59 

The absence of fecal vomiting and frequent movements, the 
good general condition, the low temperature and the short 
duration of the intussusception are all favorable points. 

Treatment. The only rational treatment for intussuscep- 
tion at any stage is immediate operation as soon as the 
diagnosis is made. Attempts at reduction by inflation of the 
bowel with water or air are in rare instances successful. In 
the vast majority of cases, however, they are unsuccessful, 
they waste time and use up the child's vitality. It is impos- 
sible, moreover, to know at once whether the intussusception 
has been reduced or not by these measures, so that on this 
account still more time is wasted. An early operation is 
usually successful, because at this time the intussusception 
can be easily reduced, while the dangers from opening the 
abdomen are slight in skilled hands. When the operation is 
delayed, the intussusception can usually not be reduced 
because of adhesions, and the bowel is irreparably damaged. 
A resection has to be done or an artificial anus made. Under 
these circumstances the baby almost invariably dies. 



60 CASE HISTORIES IN PEDIATRICS. 

CASE 17. Robert A., fifteen months old, was the first 
child of healthy parents. He was breast-fed during the first 
year and was not constipated during this time. He was then 
given a mixture of Mellin's Food and milk and became very 
much constipated. After that he was given Imperial Granum, 
and other articles of diet were soon added. When seen he was 
taking milk, oat jelly, bread, orange juice and Bovinine. 
The bowels did not move except with the aid of gluten sup- 
positories. The movements were large, brown or yellow in 
color, coated with mucus, and usually had bright blood on the 
outside. Defecation was very painful. During it the child 
became cold and perspired and stiffened out. Otherwise he 
was well. He sat up but did not creep or try to stand. He 
apparently did not have too large an amount of food. 

Physical Examination. He was good-sized but fat and 
flabby. The muscles seemed poorly developed. His color 
was good. The fontanelle was nearly closed. The tongue was 
clean. He had twelve teeth. There was a slight rosary. 
There was also a slight retraction of the chest at the insertion 
of the diaphragm. The abdomen was not distended and was 
perfectly lax. The liver was palpable 1 cm. below the costal 
border in the nipple line. The spleen was not palpable. The 
extremities were normal except for a slight enlargement of 
the epiphyses at the wrists. There was no spasm or paralysis. 
The knee-jerks were equal and normal. There was no 
Kernig's sign. There was no enlargement of the peripheral 
lymph nodes. The genitals were normal except that the 
prepuce was rather tight. There was a crack at the edge of 
the anus, both back and front, about one quarter of an inch 
long and one eighth of an inch deep. This crack bled easily 
when the anus was stretched. Rectal examination was 
negative. 

Diagnosis. The diagnosis of constipation is, of course, 
evident. This diagnosis is, however, not sufficient. It is 
necessary to determine the type and the cause of the constipa- 
tion. The pain during defecation and the bright blood on the 
outside of the movement are almost enough of themselves to 
justify the diagnosis of fissure of the anus without physical 
examination. This condition is, of course, proved by the 



DISEASES OF GASTROENTERIC TRACT. 6l 

physical examination. The fissure and the pain caused by it 
are, therefore, the cause of the constipation, and the consti- 
pation is of the spasmodic type. The large size of the move- 
ments suggests some other etiological factor. This suggestion 
is corroborated by the facts that the child does not creep or 
try to stand, and the general flabbiness. That is, the muscular 
development is poor. It is fair to assume that the intestinal 
muscles are also weak and the intestinal peristalsis feeble. 
The constipation is, therefore, partly of the atonic type. 
The cause of the weakness of the muscles is shown by the 
rosary, the retraction of the lower chest and the enlargement of 
the epiphyses at the wrists, all of them manifestations of 
rickets. The final diagnosis is, therefore, Constipation, 
chiefly of the Spasmodic Type; Fissure of the Anus; 
Mild Rickets. An interesting point is that the malt sugar 
in the Mellin's Food, which usually acts as a laxative, had 
the opposite effect in this instance. 

Prognosis. The prognosis is perfectly good with time and 
proper treatment. The fissure should heal in a few weeks 
with very simple treatment. Stretching the sphincter is 
almost never necessary. It will probably take somewhat 
longer to relieve the constipation because, on account of the 
pain in the past, the child will continue to be afraid to have a 
movement even after the fissure is healed, and the atonic 
element will remain after the spasmodic element is relieved. 
The active stage of the rickets, shown chiefly by the weak 
musculature, should yield quickly to treatment. The bony 
signs will persist for many months but will eventually dis- 
appear. 

Treatment. The first object of the treatment is to heal the 
fissure. To do this, it is first necessary to keep the movements 
soft. Until this is accomplished by regulation of the diet, it 
can best be done with an enema of an ounce of sweet oil 
daily. If this is not effectual, he may be given one or two 
teaspoonfuls of milk of magnesia in his milk daily. Local 
cleanliness and the application of boracic acid ointment will 
then quickly heal the fissure. It will almost certainly not be 
necessary to stretch the sphincter. 

A rational routine and diet for him will be as follows: 



62 CASE HISTORIES IN PEDIATRICS. 

6 a.m. Whole milk, 8 ounces. 

9 a.m. Orange juice, 2 tablespoonfuls. 

io a.m. Oat jelly, 2 or 3 tablespoonfuls. Whole milk, 10 
ounces. 

2 p.m. Mutton or chicken broth, 3 ounces; or beef juice, 
2 tablespoonfuls. Bread or zwiebach, 1 slice. One-half baked 
apple or 2 tablespoonfuls of prune juice. Whole milk, 4 
ounces, if desired. 

6 p.m. Oat jelly, 2 or 3 tablespoonfuls. Whole milk, 10 
ounces. 

Water should be forced. 

Massage of the abdomen twice daily will stimulate the 
peristalsis and improve the muscular tone. Much fresh air 
and sunlight will help the rickets and general condition, and 
hence the atonic element of the constipation. Tincture of 
nux vomica, in drop doses, three times a day, before meals, 
will also tend to improve the general condition and the intesti- 
nal tone. 



DISEASES OF GASTROENTERIC TRACT. 63 

CASE 18. Malcolm B., the third child of healthy parents, 
was born at full term after a normal labor. He was normal at 
birth and weighed eight pounds. He was nursed for nine 
months, but during the last two months had had one or two 
feedings of modified milk daily in addition. He was then 
weaned and given an unmodified top milk, which contained 
about 7.50% of fat, 4.50% of sugar and 3.50% of proteids. 
The bowels, which had previously moved regularly, immedi- 
ately became constipated, enemata, suppositories or some 
drug being always required to get a movement. The move- 
ments were white, dry and crumbling and had a disagreeable 
acid odor. There was no vomiting. He took nothing but 
this top milk, except occasionally a little broth with rice, 
until he was fourteen months old. He was then changed to 
five feedings of seven ounces of a top milk and Mellin's Food 
mixture, which contained about 5.70% of fat, 6% of sugar 
and 3% of proteids, and after about three weeks was given a 
little beef juice in addition. The constipation was rather less 
marked on this diet but still very troublesome. He was seen 
when fifteen months old. 

Physical Examination. He was well developed and nour- 
ished, but flabby and a little pale. The fontanelle was 2 cm. 
in diameter. He had seven teeth. His tongue was clean. 
There was no rosary. The heart and lungs were normal. 
The abdomen was negative, its level a little below that of the 
thorax. The liver was just palpable. The spleen was not 
palpable. The extremities were normal. There was no spasm 
or paralysis; the knee-jerks were equal and normal; Kernig's 
sign was absent. There was a slight general enlargement of 
the peripheral lymph nodes. The weight was twenty-two 
pounds and eight ounces. 

Diagnosis. The chief trouble is, of course, Constipation. 
Constipation is, however, really a symptom and not a disease. 
It is not a satisfactory diagnosis unless modified by some 
term denoting the cause of the constipation. In this instance 
the cause of the constipation is very evident, namely, the 
excessive amount of fat in the food. No more than four 
per cent of fat should ever be given ; he was getting nearly 
twice that. The white, dry and crumbling stools are most 



64 CASE HISTORIES IN PEDIATRICS. 

characteristic, being composed of unutilized fat in the form 
of soaps. The improvement after the change of food, one 
result of the change being a reduction in the amount of fat, is 
further evidence that an excess of fat was the cause of the 
constipation. A part of the improvement may possibly, 
however, be attributed to the malt sugar in the Mellin's Food 
and the beef juice, both of which usually have a laxative 
action. The flabbiness of the skeletal muscles indicates an 
additional atonic element in the etiology, because, when the 
skeletal muscles are feeble, the intestinal muscles are usually 
in the same condition. 

Prognosis. The prognosis is good for rapid recovery, 
because the chief cause of the trouble, the excess of fat in the 
food, can be removed at once. 

Treatment. The treatment is, of course, primarily by 
regulation of the diet to remove the cause of the trouble. 
Whole milk, or whole milk with an ounce of oat water to 
each feeding, will probably give a sufficiently low fat. He is 
old enough to have something beside milk; infact, babies of 
his age are almost certain to do badly in some way if they do 
not have something to eat beside milk. A reasonable diet to 
start him on is as follows: 

Whole milk or whole milk with oat water. 

Beef juice, one or two tablespoonf uls ; or 

Mutton or chicken broth, two to four ounces, once daily. 

Bread or zwiebach in broth or beef juice. 

Barley jelly, oat jelly, farina or rice, one to three table- 
spoonfuls twice daily. 

Orange juice, one to three tablespoonfuls, once daily. 

While regulation of the diet is removing the cause of the 
trouble, it may be necessary to relieve the symptom, constipa- 
tion, for a time by the use of enemata of suds or sweet oil, 
suppositories of soap, glycerin or gluten, or milk of magnesia, 
in doses of from one-half to one teaspoonful once or twice 
daily. 

It goes without saying that fresh air, a good routine and 
everything which tends to improve the general condition will 
aid in the relief of the constipation by improving the muscular 
tone and removing the atonic element. 



DISEASES OF GASTRO-ENTERIC TRACT. 65 

CASE 19. Charles B., seven and one-half years old, was 
not very carefully fed, but had not been especially indiscreet 
just before the onset of this illness. He had had a number of 
similar attacks in the past. 

He complained of pain in his stomach in the late afternoon 
of December 2, and vomited a considerable amount of un- 
digested food and mucus mixed with bile. His temperature 
that night was 104 F. He nevertheless slept well. He 
vomited several times during the next two days and the 
vomitus always contained bile. The bowels did not move 
either day, as all the drugs given were vomited. His tempera- 
ture ranged between ioo° F. and 102 F. He had no pain. 
He did not seem very sick, but did not care to get out of bed. 
He did not want anything to eat, but had taken a little milk 
and broth. A dose of Epsom salts given on the morning of 
the 5th was retained and resulted in several large, loose, 
gray or light grayish-yellow movements, which had a very 
foul odor, but did not contain undigested food or mucus. 
Slight yellowishness of the conjunctivae was noticed that 
afternoon. He was seen at 4 p.m., December 5. 

Physical Examination. He was well-developed and nour- 
ished and perfectly clear mentally. He was a little pale. 
The conjunctivae had a slight yellow tinge. The tongue was 
moist and moderately coated; the papillae were unusually 
distinct. The mouth and throat were normal. There was no 
rigidity of the neck. The heart and lungs were normal. The 
level of the abdomen was below that of the thorax. There 
was no muscular spasm or tenderness and no masses were 
felt. The upper border of the liver flatness was at the upper 
border of the sixth rib in the nipple line. The liver was 
palpable just below the costal border in the nipple line. It 
was not tender. The gall-bladder was not palpable and there 
was no tenderness in this region. The spleen was not palpable. 
The extremities were normal. There was no spasm or 
paralysis; the knee-jerks were equal and normal; there was 
no Kernig's sign. There was no enlargement of the peripheral 
lymph nodes. The rectal temperature was 99. 2 F. ; the 
pulse was 80. 

The urine was clear and dark reddish yellow in color; when 



66 CASE HISTORIES IN PEDIATRICS. 

shaken the froth was yellow. The reaction was acid; the 
specific gravity, 1,024. It contained neither albumin, sugar 
nor acetone. The sediment showed nothing abnormal. 

Diagnosis. Inflammation of the gall-bladder and gallstones 
are extremely rare at this age. The absence of pain and of 
enlargement and tenderness of the gall-bladder, together 
with the low temperature, exclude them in this instance. 
The vomiting of bile, the enlargement of the liver (which 
should not be palpable at this age), the yellowness of the 
conjunctivae, the clay-colored stools and the dark urine are 
so characteristic of Acute Duodenal Indigestion that it 
is hardly necessary to exclude other diseases. A number 
of other conditions ought, perhaps, to be considered, how- 
ever, for the sake of completeness. These are, acute gastric 
indigestion, recurrent vomiting and appendicitis. None of 
them show jaundice, clay-colored stools or bile in the urine. 
There is none or very little fever in recurrent vomiting, and 
there are local signs in the abdomen in appendicitis. Tuber- 
cular meningitis should be thought of in this instance, as 
always when a child vomits. It can, of course, be excluded 
at once on the presence of the characteristic symptoms of 
duodenal indigestion and the absence of all signs of meningeal 
irritation. 

Prognosis. There is, of course, no danger as to life. The 
most acute stage is already over. It will probably be one or 
two weeks, however, before bile reappears in the movements 
and convalescence really begins. During this time, while not 
seriously ill, he will be very miserable and irritable. If he is 
neglected or improperly treated, there is considerable danger 
that the condition will run over into chronic duodenal indi- 
gestion. He is almost certain to have more attacks in the 
future, unless great care is taken with his diet. 

Treatment. The most acute stage being over, the treat- 
ment is now principally regulation of the diet. Experience 
has shown that these patients do best when they are fed almost 
entirely on proteids, the starches being kept low, and the 
fats and sugars entirely excluded. A reasonable diet for him 
at present is whey, skimmed milk, junket from skimmed 
milk, strained broths, beef juice, white of egg, and toast 



DISEASES OF GASTRO-ENTERIC TRACT. 6j 

bread and zwiebach in small amounts. Lean meat and simple 
cereals may be added to his diet as he improves ; next, orange 
juice and green vegetables. It is always wise to wait longer 
than seems necessary before increasing the diet. 

There is no drug which will diminish the swelling in the 
duodenum or at the orifice of the common bile duct. Time 
and rest of the duodenum by care in the diet will alone accom- 
plish this. The so-called " cholagogues " are contra-indicated 
for two reasons: they do not increase the flow of bile and 
there would be no object in increasing it, if they did. Phos- 
phate of soda in doses of a teaspoonful, more or less, is the 
best laxative. Tincture of nux vomica seems to be of some 
utility in these cases and is worthy of a trial. Seven drops, 
three times a day, before eating, is about the right dose for 
this patient. 

He must be kept in bed and kept warm until convalescence 
is well established, because over-exertion and chilling are 
very apt to bring on a relapse. 



68 CASE HISTORIES IN PEDIATRICS. 

CASE 20. Russell H., three years old, was born at full 
term, was normal at birth and weighed ten and one-half 
pounds. His parents were healthy and there had been no 
known exposure to tuberculosis. He was breast-fed and when 
six months old weighed thirty pounds. His mother began to 
give him other food very early and for the past year his diet 
had been very unsuitable for a child of his age. He was given 
very little meat or vegetables, but many sweets and bananas. 
His appetite had been poor for nearly six months, during 
which time he had lost eight pounds. Recently it had been 
necessary to force him to eat., He had not vomited, but was 
inclined to constipation. The movements were at times 
greenish; at others, clay-colored. They never contained 
mucus. He had been very forward up to the past six months. 
Since then he had grown steadily weaker, so much so that he 
had fallen down several times on a short walk two days be- 
fore. His mother said that he " seemed tired all the time," 
and that he did not " romp and play " as formerly. He was 
irritable and picked his nose a great deal. His mother, sus- 
pecting worms, had given him "True's Elixir " several times, 
but had never obtained any worms. He had had no serious 
illnesses, merely an occasional cold. 

Physical Examination. He was fairly developed and nour- 
ished. His color was fair. There was no jaundice. His 
tongue was moist and moderately coated; the papillae were 
unusually distinct. There was a tendency to keep his mouth 
open and a small amount of adenoids was felt with the 
finger. The tonsils were not enlarged. The heart and lungs 
were normal. The liver and spleen were not palpable. The 
abdomen was moderately enlarged, but lax. There were no 
indications of fluid and no masses were felt. The extremities 
were normal. There was no spasm or paralysis; the knee- 
jerks were equal and normal. There was no enlargement of 
the peripheral lymph nodes. He weighed thirty-seven pounds. 

The urine was pale, acid in reaction and contained neither 
albumin nor sugar. 

Diagnosis. Loss of appetite, progressive failure in weight 
and strength and irritability are symptoms common to so 
many diseases that they are of no special importance in diag- 



DISEASES OF GASTROENTERIC TRACT. 69 

nosis. The history of over-feeding with sweets and bananas 
and of clay-colored stools, together with the enlargement of 
the abdomen, when taken with these other symptoms, are, 
however, most characteristic of Chronic Duodenal Indi- 
gestion and amply sufficient to justify that diagnosis. The 
moist coated tongue with prominent papillae is another point 
in favor of this disease. The only other possibility worthy 
of serious consideration is chronic diffuse tuberculosis. While 
this might account for the general symptoms, chronic duo- 
denal indigestion does so equally well. There are no local 
manifestations of tuberculosis, and several of the character- 
istic symptoms and signs of chronic duodenal indigestion are 
present. Tuberculosis can, therefore, be ruled out. 

The mother's diagnosis of " worms " would not be worth 
mentioning if this diagnosis was not made so often, not only 
by mothers and grandmothers, but also by doctors who 
ought to know better, when children lose their appetite and 
are irritable, especially if they pick their noses. None of 
these symptoms are characteristic of the presence of worms. 
Picking the nose is merely a manifestation of nervousness; 
irritability and anorexia of a host of conditions. In fact, the 
author's experience leads him to believe that when children 
are thought to have worms they are almost invariably suf- 
fering from some other trouble and that when worms are 
found the children usually seem perfectly well. The absence 
of worms in the stools after the administration of an anthel- 
mintic rules them out in this instance. 

Prognosis. There is no danger to life except from inter- 
current disease, to which the child is predisposed by his 
weakened condition. Recovery is likely to be slow at best 
and to be interrupted by relapses. How rapidly he improves 
depends largely on how carefully the mother follows direc- 
tions. It will be two or three months, at any rate, before he 
is well. He is very likely to have a recurrence of his trouble 
unless he is very carefully fed and watched over for several 
years. 

Treatment. The treatment is mainly dietetic. Sweets 
and fats must be entirely excluded from his diet for a time, 
and starches given only in moderation. The following diet is 
a reasonable one for him: 



70 



CASE HISTORIES IN PEDIATRICS. 



Skimmed milk. 
Mutton broth. 
Chicken broth. 
Beef broth. 
Beef juice. 
White of egg. 
Lamb chop. 
Mutton chop. 
Roast chicken. 
Boiled chicken. 
Roast lamb. 
Roast mutton. 
Beef steak. 
Roast beef. 
Scraped beef. 



Boiled fish. 
Stale bread. 
Toast bread. 
Whole wheat bread. 
Milk toast. 
Zwiebach. 
Plain crackers. 
Educators. 
Barley jelly. 
Oatmeal jelly. 
Pettijohn. 
Cream of wheat. 
Wheat germ- 
Farina. 
Rice. 



Baked potato. 
Mashed potato. 
Plain macaroni. 
Peas. 

String beans. 
Spinach. 
Asparagus. 
Summer squash. 
Lettuce. 
Stewed celery. 
Orange juice. 
Junket. 
Blanc mange. 
Tapioca. 



After he begins to improve, the amount of the starches may 
be increased, then yolk of egg and a little butter added, and 
finally whole milk substituted for skimmed milk. It is wise, 
however, to be very cautious about increasing the diet. 
Sugar, or foods containing sugar, must not be given for many 
months; saccharin may be used in its place if necessary. 
Hygienic treatment is also of importance. It is especially 
necessary to avoid fatigue and chilling. He should take a 
rest of one or two hours at noon, get up late and go to bed 
early, and be warmly dressed, especially about the abdomen. 

Tincture of nux vomica seems to help this condition. 
The dose for this boy is three drops, three times a day, before 
meals, given in a little water, not in syrups or mixtures. 
He may not like it, but he can be made to take it. Phosphate 
of soda and cascara sagrada are the best laxatives, if any 
are needed. 



DISEASES OF GASTRO-ENTERIC TRACT. J I 

CASE 21. John F., the third child of healthy parents, 
was born at full term after a normal labor, was normal at 
birth and weighed eight pounds and twelve ounces. He was 
put at once on a weak modified milk, as there was no breast 
milk. The milk was gradually strengthened until, when he 
was three and one-half weeks old, he was taking a mixture 
containing about 5% of fat, 3.50% of sugar and 1% of pro- 
teids. He thrived on this until he was five weeks old, when 
his temperature suddenly rose to 103. 8° F. and his abdomen 
became distended. He then had a large, watery, green, foul 
movement and the temperature dropped to 100. 8° F. He 
was given a half a teaspoonful of castor oil and put on barley 
water containing 1.50% of starch. He had several small 
movements like the first from the castor oil. Twenty-four 
hours later, as he seemed much better, his mother put him 
back on the milk mixture. The temperature rose again in a 
few hours to 103. 8° F., the abdomen became distended again 
and he became stupid and twitchy. He was seen in con- 
sultation that evening. 

Physical Examination. He was fairly developed and nour- 
ished and of fair color. The fontanelle was a little depressed. 
There was no rigidity of the neck. The pupils were equal and 
reacted to light. The mouth was dry; the tongue slightly 
coated. The heart and lungs were normal. The abdomen 
was much enlarged, tense and everywhere tympanitic. There 
was no localized muscular spasm. The liver and spleen were 
not palpable. The extremities were normal. There was 
considerable spasm of both arms and legs with a tendency to 
twitching; there was no paralysis; the knee-jerks were equal 
and lively; Kernig's sign was absent. There was no enlarge- 
ment of the peripheral lymph nodes. There was no evidence 
of inflammation about the navel. The rectal temperature 
was 103. 5 F. 

Diagnosis. There can be no doubt, of course, that the 
location of the disturbance is in the intestine. The green, 
foul movements, the high temperature and the evidences of 
toxic absorption show that there is something more than a 
disturbance of the equilibrium of digestion, that fermentative 
processes are going on in the bowel and that the condition is 



72 CASE HISTORIES IN PEDIATRICS. 

bacterial in origin. The small number of movements and 
the absence of mucus and blood show that the intestinal wall 
is probably not involved. The diagnosis is, therefore, Acute 
Intestinal Indigestion of the Fermentative Type. 

The stupor, the spasm of the extremities and the tendency 
to twitching would be considered by many to be evidences of 
a complicating meningitis. Meningitis is, however, a very 
unusual complication of the acute diarrheal diseases of in- 
fancy, while symptoms of meningeal irritation are not at all 
uncommon. Meningitis is, therefore, extremely improbable 
in this instance. The depression of the fontanelle alone is, 
moreover, almost sufficient to rule it out. The nervous symp- 
toms are to be regarded, therefore, merely as evidences of 
toxic absorption, or possibly as effects of the high temperature. 

It is possible that the excessive amount of fat in the food 
may have predisposed the baby to this attack by disturbing 
the equilibrium of the digestion. 

Prognosis. The condition is a grave one because of the 
age of the patient, the distention of the abdomen, the high 
temperature and the presence of nervous symptoms. The 
facts that the temperature dropped and the general condition 
improved rapidly after he was cleaned out and the milk 
stopped make it probable that a repetition of the treatment 
will have the same result. Put in figures, the chances are 
probably about three to one in favor of recovery. 

Treatment. The first thing to do is to empty the bowels. 
Castor oil is the safest and most effectual drug for this pur- 
pose. As the object of the oil is to clean out the bowels, the 
dose must be large enough to do it. Two teaspoonfuls is none 
too large, even for a baby of five weeks. In the meantime the 
colon should be irrigated in order to relieve the distention and 
empty the lower bowel. It will probably not be necessary 
to repeat it unless the distention recurs, because the chief 
seat of the trouble is in the small, not in the large, intestine. 

All food must be stopped. Babies bear the withdrawal of 
food without much difficulty, but cannot get on without 
water. They must be given as much water in the twenty- 
four hours as they normally get in their food. This baby 
needs at least twenty ounces of water in the twenty-four 



DISEASES OF GASTRO-ENTERIC TRACT. 73 

hours. If he will not take it from the bottle, spoon or dropper, 
it must be given with a stomach tube. In urgent cases it 
may be given by the bowel by the drop method, or subcu- 
taneously in the form of physiological salt solution. It will 
probably not be necessary to have recourse to these measures 
in this instance. The water not only prevents the loss of 
fluid from the tissues, thus keeping up the equilibrium of 
the circulation, but favors the elimination of toxic substances 
through the kidneys. 

The duration of the period of starvation depends on the 
temperature, the character of the movements and the general 
condition of the patient. It is impossible to state in advance 
how long this period will be in any individual case. In all 
probability, not more than twenty-four or forty-eight hours 
in this instance. 

It is wiser, on general principles, to begin feeding with some 
other food than milk. This is usually some form of starch 
or sugar. This baby is only five weeks old and ought not to 
have its power of digesting starch pushed too hard. A 0.75% 
solution of starch in the form of barley water, with 7% of 
milk sugar, will be suitable to begin with. 

When it is time to begin milk the best milk is human milk. 
Nothing else compares with it in these conditions. Next to 
it is modified cow's milk. In general, it is wiser to begin with 
some combination very low in fat. The substitution of whey 
for some of the feedings of barley water and sugar will be a 
good way to begin in this instance. The addition of a small 
amount of skimmed milk to the barley water and sugar mix- 
ture is another way. Another is a whey mixture low in fat 
and relatively high in proteids, such as fat 1%, sugar 6%, 
whey proteids 0.75%, casein 0.25%, without lime water. 

There are no drugs which can have any effect on the local 
condition. No stimulants are needed at present. The castor 
oil and irrrigation will, in all probability, relieve the disten- 
tion. The temperature is not high enough or the nervous 
manifestations marked enough to require special treatment. 
The emptying of the bowels and the water diet will diminish 
the toxemia, and the temperature and nervous symptoms, 
which are caused by it, will then gradually disappear. 



74 CASE HISTORIES IN PEDIATRICS. 

CASE 22. Dana B., the second child of healthy parents, 
was delivered at full term by low forceps and weighed eight 
pounds and nine ounces. He was much asphyxiated as the 
result of two turns of the cord about his neck, and did not 
breathe well until he was two days old. He was nursed, with 
one feeding of a mixture containing 4% of fat, 6% of sugar 
and 0.50% of proteids, daily, for two weeks. During this 
time he did not vomit, had some colic and was slightly con- 
stipated. His weight dropped to seven pounds and two 
ounces. He was then weaned and given a mixture of about 
the same strength. He did not vomit, but had several green 
and curdy movements daily. Two weeks later he was changed 
to a mixture containing 3% of fat, 3.25% of sugar and 2.50% 
of proteids, which he took for a week. He did not vomit, but 
the movements were of the same character. The next week 
he had a mixture containing 4% of fat, 1.10% of sugar, 
0.80% of proteids and 1.10% of starch. The story was the 
same as before. He was finally put on a Mellin's Food mix- 
ture containing 3.70% of fat, 4% of sugar and 1.15% of 
proteids, which he was taking when seen in consultation, 
when two months old. He took ten feedings of three ounces, 
giving about 150 calories and 3.2 grams of proteid per kilo. 
He did not vomit, but was constipated. The movements, 
which were yellow, contained small curds and much mucus. 
He was taking olive oil for the constipation. He had lost 
seven ounces in the last week on this mixture and weighed 
seven pounds and two ounces, about one and one-half pounds 
less than at birth. He had had no fever at any time. 

Physical Examination. He was small and poorly nourished, 
but of fair color. The fontanelle was a little depressed. 
The bones of the skull did not overlap. He was bright and 
intelligent. His mouth was healthy, his tongue clean. There 
was no rosary. The heart and lungs were normal. The 
abdomen was a little sunken, but otherwise normal. The 
liver was just palpable, the spleen was not palpable. The ex- 
tremities were normal. There was no spasm or paralysis; 
the knee-jerks were not obtained; Kernig's sign was absent. 
There was no enlargement of the peripheral lymph nodes. 

A movement which was seen was small, loose, greenish- 



DISEASES OF GASTROENTERIC TRACT. 75 

yellow in color, without odor, and composed mostly of mucus, 
with a few small, soft, green and yellow curds. 

Diagnosis. The trouble in this instance is undoubtedly 
digestive. The absence of vomiting and the persistence of 
undigested movements show that the trouble is intestinal and 
not gastric. The absence of fever and of signs of fermenta- 
tion in the movements rule out infectious diarrhea and in- 
testinal indigestion of the fermentative type. The diagnosis 
is, therefore, Chronic Intestinal Indigestion of the type 
due to disturbance of equilibrium. 

The cause is, of course, to be sought in the food. He was 
undoubtedly underfed while on the breast. While on the 
bottle he was somewhat overfed most of the time. The 
fats were no higher than most babies can digest, but were 
more than he was able to handle, as is shown by the small, 
soft curds in the movements. It was a mistake to give olive 
oil for the constipation, because it increased the amount of 
fat to be handled when the baby was already unable to take 
care of that in the food. It is very probable that it also in- 
creased the tendency to constipation. The proteids were at 
times too low to cover the proteid need, at other times much 
too high. There were, however, at no time any definite 
signs of proteid indigestion. The sugars were usually too 
low, but were apparently well digested. 

Prognosis. Although he has lost considerable weight, his 
general condition is fairly good and the movements not very 
bad. It ought not to be very difficult, therefore, to fit the 
food to his digestive capacity. It will, however, probably 
take a good many weeks to get him to digesting properly 
and gaining regularly. 

Treatment. The treatment consists, of course, in regula- 
tion of the diet. The best food is human milk. It is not 
a necessity in this instance, however, as he will almost cer- 
tainly do well on suitable modifications of cow's milk. If he 
does not, a wet nurse can be obtained later. The history 
gives two fairly definite indications as to the regulation of the 
diet. They are to give him less food and to cut down the fat. 
The calories lost by cutting down the fat can be made up, if 
necessary, by giving more sugar, which he is able to digest. 



76 CASE HISTORIES IN PEDIATRICS. 

Whey proteids are more easily digested than casein. It will 
be well, therefore, to start him on a. whey mixture. Lime 
water is contra-indicated because it throws work from the 
stomach on to the intestine, which is the part involved. The 
following mixture is a suitable one : 

Fat, 2.00% 

Sugar, 7-00% 

Whey proteids, 0.75% 

Casein, 0.25% 

He should have ten feedings of two and a half ounces. 
This gives about 120 calories and 2.3 grams of proteid per kilo. 

The constipation will probably take care of itself after 
regulation of the diet. If not, enemata or suppositories will 
be better in this instance than drugs by mouth. 



DISEASES OF GASTRO-ENTERIC TRACT. 77 

CASE 23. Sally B., three and one-half months old, was 
born at full term after a normal labor and weighed six and 
one-fourth pounds. She was breast-fed for ten days, when 
the milk gave out and she was put on modified milk. She 
got on very well indeed until she was two months old, when 
she weighed nine pounds. She then had a severe attack of 
influenza and was very ill for about two weeks. During her 
illness she lost some weight and was left much depressed 
generally. She had finally begun to digest well again and had 
a little more than regained her weight. She was taking eight 
feedings of three ounces of a mixture, prepared at a laboratory, 
supposed to contain 2.50% of fat, 5.50% of sugar, 0.50% of 
whey proteids and 0.25% of casein, with lime water 10% of 
the total quantity. It was winter and the mixture was 
pasteurized at 155 F. 

Without any known cause she began to vomit and to have 
much gas and discomfort. The vomitus smelled sour. She 
also began to have watery, light-green movements of a sour 
odor, which did not contain curds or mucus, and which 
irritated the buttocks. She had no fever. 

Physical Examination. She was fairly developed and nour- 
ished. There was moderate pallor. The anterior fontanelle 
was 3 cm. in diameter and slightly depressed. The tongue 
was slightly reddened. There was no rosary. The heart and 
lungs were normal. The abdomen was slightly distended, but 
otherwise normal. The liver was palpable 2 cm. below the 
costal border in the nipple line. The spleen was not palpable. 
The extremities were normal. There was no spasm or pa- 
ralysis ; the knee-jerks were equal and normal ; there was no 
Kernig's sign. The rectal temperature was 98 F. The 
stools were as described above. 

Diagnosis. The negative physical examination and normal 
temperature rule out everything outside of the digestive 
tract. The absence of fever, the time of year and the pasteuri- 
zation of the food make a bacterial infection very improbable. 
The cause of the trouble must, therefore, be sought in the 
food. The combination of sour vomiting, flatulence and 
watery, green, sour, irritating stools points strongly to 
trouble in the digestion of the sugar. This hardly seems rea- 



70 CASE HISTORIES IN PEDIATRICS. 

sonable, however, in a baby that had for months been taking 
from five per cent to seven per cent of milk sugar without 
trouble. Analysis of the food by a competent chemist showed, 
however, that it contained nearly ten per cent of sugar. 
The fat and proteid contents were reasonably accurate. 
The diagnosis, therefore, is Acute Gastric and Intestinal 
Indigestion from an excessive amount of sugar. 

Prognosis. The prognosis is good, as the cause of the 
trouble can easily be remedied. 

Treatment. The treatment is, of course, the correction of 
the mistake in the preparation of the food. As this mixture 
gives but 86 calories and 1.3 grams of proteid per kilo, it 
will also be well to increase the percentage of the proteids a 
little. 



DISEASES OF GASTRO-ENTERIC TRACT. 79 

CASE 24. Mary S., six months old, was the fourth child 
of healthy parents. There had been no known exposure to 
tuberculosis. She was born at full term after a normal labor, 
was normal at birth and weighed five and one-half pounds. 

She was started at first on a weak mixture, copied from 
Dr. Holt's little book, " The Care and Feeding of Children," 
and did very well for a time. The gain in weight was, how- 
ever, very slow, and she did not reach eight pounds until she 
was five months old. She had lost half a pound since then. 
Because of the slow gain in weight, the physician in charge 
rapidly strengthened the formulae, but apparently never 
inquired into the details of the preparation of the food. The 
parents, being even more anxious than the physician to have 
the baby gain in weight, used gravity cream from Jersey 
milk instead of the 10% top milk specified in the book, and 
finally bought thick, pasteurized cream from a dealer. Her 
appetite became very poor. When she came to me, when 
six months old, her mother was attempting to give her eight 
feedings of four ounces at two and one-half hour intervals. 
She seldom took more than twenty ounces in the twenty-four 
hours, however, and this only after much urging, two and a 
half hours often being needed to get in two and one-half 
ounces. She seldom seemed hungry, but, if she did, was 
always satisfied with an ounce. She never vomited unless 
the food was forced too much. She occasionally had a little 
colic but always had a good deal of rumbling in the abdomen 
and passed much gas from the bowels. The bowels were 
usually constipated. The movements were small, crumbly, 
very light yellow, apparently well digested and without much 
odor. She was taking the following mixture: 

Pasteurized rich cream, 5i ounces. 

Whole milk (Jersey), i\ ounces. 

Lime water, \\ ounces. 

Water, i8^ ounces. 
Milk sugar, i dessertspoonful. 

Physical Examination. She was small and thin and moder- 
ately pale. She was feeble but intelligent. The veins on the 
scalp were prominent. The anterior fontanelle was 3 cm. in 
diameter and level. The posterior fontanelle was still open. 



80 CASE HISTORIES IN PEDIATRICS. 

There was no craniotabes. The throat was normal; the 
tongue somewhat reddened. There were no teeth. There 
was a marked rosary. The heart and lungs were normal. 
The abdomen was large, but lax. There was no dullness and 
no tumor was made out. The liver was palpable 3 cm. 
below the costal border in the nipple line. The spleen was 
not palpable. The extremities were normal. There was no 
spasm or paralysis; the knee-jerks were equal and normal; 
there was no Kernig's sign. There was no enlargement of the 
peripheral lymph nodes. Her weight was seven and one-half 
pounds. 

Diagnosis. The physical examination justifies nothing more 
than the diagnosis of malnutrition with a slight and unim- 
portant amount of rickets. The cause of the malnutrition 
must be sought in the history. The satiation after taking a 
small amount of food, taken in connection with the lack of 
marked symptoms of indigestion and the slow gain, suggest 
at once too rich a food. The small size, crumbly character 
and light-yellow color of the stools are very characteristic 
and show that they contain fat in the form of soap. The 
story of the substitution of gravity cream from Jersey cows 
for 10% top milk from ordinary cows, and later of rich bottled 
cream for the gravity cream, corroborates, of course, the 
assumption that the food was too rich in fat. It shows also 
how necessary it is for the physician to know exactly how the 
food which he orders is prepared. 

The mixture which the baby was taking, if made of 10% 
cream and whole milk from Holstein or Ayreshire cows, as 
it was supposed to be, would contain about 2.40% of fat, 
3.25% of sugar and 0.90% of proteids, a weak food for the 
age. If made of gravity cream from average milk it would 
have contained about 340% of fat. The modified milk in 
the bottle, however, looked like cream, and when examined 
was found to contain 8.8% of fat. 

The diagnosis is, therefore, Indigestion (chiefly intestinal), 
malnutrition and rickets from an Excess of Fat in the 
Food. The author wishes to call particular attention to the 
fact that in this instance, as in almost all others of disturbed 
nutrition or digestion from an excess of fat in the food, the 



DISEASES OF GASTRO -ENTERIC TRACT. 8 1 

excess was a gross one, the amount being far beyond the 
normal top limit of 4%. 

Prognosis. The prognosis is good on a reasonable diet. 
The gain in weight will probably be slow, and it will be a 
long time before the baby will be able to take as high a per- 
centage of fat as the average baby, as it is always difficult to 
develop the ability to digest fat again when it has once been 
seriously impaired. 

Treatment. The treatment is entirely by regulation of the 
diet. Human milk would be the best food and would almost 
certainly agree, in spite of its comparatively high fat content. 
Next to this is some modification of cow's milk. The milk 
should come from Ayreshire or Holstein cows. The per- 
centage of fat should be low because of the impaired power of 
digestion of fat. The caloric value can be made up by higher 
percentages of sugar and proteids. There is no indication 
for the addition of an alkali. Three ounces is as much as she 
ought to be expected to take at a feeding. Eight feedings, 
at two and a half hour intervals, will be sufficient. The 
following formula is a suitable one: 

Fat, 2.50% 

Sugar, 5-00% 

Proteids, 1-25% 

This gives 100 calories and 2.6 grams of proteid per kilo. 

The baby should not be fed at other than the regular inter- 
vals and, if she does not take the food willingly, the attempt 
to make her take it should not be prolonged over half an 
hour. If the constipation persists it may be treated by 
enemata of suds or sweet oil, or by suppositories of soap, 
glycerin or gluten, but not by sweet oil by the mouth. 



82 CASE HISTORIES IN PEDIATRICS. 

CASE 25. John B., the fifth child of healthy parents, was 
born at full term after a normal labor. He was normal at 
birth and weighed eight and three-fourths pounds. He was 
not nursed, but was started at once on a modified milk con- 
taining 2.50% of fat, 5.50% of sugar, 0.80% of proteids, with 
lime water 5% of the total quantity. He did not thrive on 
this and was soon put on a mixture containing 3.40% of fat, 
6.50% of sugar, 1.50% of proteids and 0.75% of starch. The 
lime water was still 5% of the total quantity. He took this 
well, but was not satisfied. He did not vomit, but was 
constipated. The movements contained many large, tough 
curds, but were of good color and did not contain mucus. 
When four weeks old he was changed to a pancreatized mix- 
ture containing 3% of fat, 3.50% of sugar and 2% of proteids. 
When seen, at five months, he was still taking this mixture, 
getting six or seven feedings of four ounces at three-hour 
intervals. Seven feedings of four ounces of this mixture 
gives 106 calories and 4.2 grams of proteid per kilo. He was 
also taking two teaspoonfuls of olive oil daily. He did not 
vomit, but had considerable gas. The bowels did not move 
without laxatives. The movements were light green or yellow 
in color and always contained large, hard curds, but no 
mucus. He did not gain in weight. 

Physical Examination. He was bright and happy. He 
was small and thin and his color was fair. The fontanelle 
was 3 cm. in diameter and level. The bones of the skull did 
not overlap. The tongue was slightly reddened; the mouth 
and throat were otherwise normal. There was no rosary. 
The heart and lungs were normal. The level of the abdomen 
was slightly below that of the thorax ; nothing abnormal was 
detected in it. The liver was palpable 1 cm. below the costal 
border in the nipple line. The spleen was not palpable. The 
extremities were normal. There was no spasm or paralysis; 
the knee-jerks were equal and normal ; there was no Kernig's 
sign. There was no enlargement of the peripheral lymph 
nodes. His weight was eight pounds and thirteen ounces. 

Diagnosis. The physical examination justifies nothing 
more than a diagnosis of malnutrition. The slight reddening 
of the tongue is probably merely the result of local irritation 



DISEASES OF GASTRO- ENTERIC TRACT. 83 

from the nipple, but may be a manifestation of gastric indi- 
gestion. The large, hard curds in the movements show that 
the casein is not properly digested. The amount of proteid 
in the food, 4.2 grams of proteid per kilo, is, moreover, 
excessive. There is nothing about the movements to show 
any disturbance of the digestion of either fat or sugar. The 
absence of vomiting, combined with the constipation and the 
flatulence, point to intestinal indigestion rather than to 
gastric. The failure to gain and the constipation suggest 
an insufficient supply of food. One hundred and six calories 
per kilo ought, theoretically, to be enough, but probably is 
not, as the caloric needs presumably depend somewhat on the 
age as well as on the weight. That is, a well baby of five 
months needs more calories per kilo than a fat baby of the 
same weight of one month. The diagnosis of malnutrition 
from an insufficient supply of food, and mild Intestinal 
Indigestion from an Excess of Proteids in the Food is, 
therefore, justified. 

Prognosis. The cheerfulness and the absence of marked 
signs of wasting show that the disturbance of nutrition is 
not a severe one. The disturbance of digestion is only in that 
of the proteids. These can be easily considerably lowered 
and still cover the proteid needs, while the fat and sugar can 
be increased to cover the caloric needs. The prognosis is, 
therefore, good. 

Treatment. The treatment is, of course, entirely by regu- 
lation of the diet and not by the administration of drugs. 
Human milk, as in all the chronic disturbances of digestion 
or of malnutrition in infancy, is the best food. In this 
instance, however, it does not seem a necessity. 

The caloric value of the food can best be increased by rais- 
ing the percentage of sugar to 7, as the sugar is at present 
altogether too low. There is also no objection to giving five 
ounces at a feeding. After this is done it will not be necessary 
to increase the percentage of the fat, which is now a reason- 
able one. The percentage of proteids should be lowered 
somewhat, as the excessive amount is throwing unnecessary 
work on the eliminative organs, and they are not needed to 
keep up the caloric value of the food, which can be supplied 



84 CASE HISTORIES IN PEDIATRICS. 

by the fat and sugar, which are digested. A considerable 
proportion of the proteids should be given in the form of 
whey proteids, as the large curds show that it is the casein 
which is not digested. An alkali is not indicated, as there is 
no vomiting. The following formula meets these indications : 

Fat, 3-00% 

Sugar, 7-<>o% 

Whey proteids, 0.75% 

Casein, 0.25% 

Seven feedings of five ounces of this mixture give 159 
calories and 2.6 grams of proteid per kilo. 

Another method of rendering the casein more digestible is 
by the addition of starch to the food, which by its mechanical 
action prevents the formation of large curds; 0.75% of starch 
has as much effect as larger amounts. There is no objection 
to giving this amount of starch because, while it is true that 
the amylolytic function is only partially developed at this 
age, it is practically always sufficiently developed to take 
care of this or even somewhat larger amounts of starch 
without difficulty. This action of starch is, however, rather 
unreliable. Peptonization, or, as it should be called, pancreat- 
ization, of the food, if properly done, also usually prevents 
the formation of large curds. If not properly done, as was 
probably the case in this instance, it is ineffective. 

The reddened tongue requires no treatment. Change of 
nipples and regulation of the diet will correct it. 

The bowels may be moved, if necessary, by enemata of 
suds or sweet oil, suppositories of soap, gluten or glycerin, or 
by milk of magnesia, in doses of from one-half to one tea- 
spoonful, once or twice daily. 



DISEASES OF GASTRO-ENTERIC TRACT. 85 

CASE 26. Catherine L., six and one-half years old, was 
the first child of healthy parents. She was born about a month 
premature and for the first year had a feeble digestion and 
was very difficult to feed. During the first two years of her 
life she had repeated attacks of vomiting, some of which 
resembled the recurrent vomiting seen in older children. 
After this, however, these attacks ceased, although her diet 
always had to be very carefully regulated. There was always 
a tendency to constipation and to duodenal indigestion. 
She had never had any severe attacks of duodenal indigestion, 
however, as they could always be aborted by care in the diet 
and early treatment. During the last year her digestion had 
been much stronger than ever before. Early in June she had 
an attack of what was supposed to be duodenal indigestion. 
Recovery from this was rapid, however, and she had been 
perfectly well until August 2 1 . That afternoon she went to a 
children's party and was a good deal excited. The food at the 
party was very simple and she did not over-eat. She began to 
vomit during the night. The vomitus contained a great deal 
of bile. The morning of the 22d her temperature was about 
ioo° F. She continued to vomit bile during the day and 
night of the 22d, and also a little in the morning of the 23d. 
The vomitus continued to contain much bile. The tempera- 
ture during the 22d and the morning of the 23d ranged 
between ioo° F. and 101 F. Examination of the abdomen 
during the 22d showed nothing whatever abnormal. In the 
early morning of the 23d there was a little tenderness in the 
right iliac fossa, with a suggestion of spasm. There was and 
had been no pain in the abdomen. The bowels had been 
moved freely by enemata during the 22d. About noon of 
the 23d she had a chill and the temperature rose to 104 F., 
but soon began to drop again. At that time there was no 
pain in the abdomen, but muscular spasm and tenderness in 
the right iliac fossa were rather more marked. The blood 
count at that time showed 26,200 leucocytes. 

She was then given a dose of castor oil, which during the 
afternoon produced a movement containing more or less 
mucus. She was seen in consultation at 5 p.m. on the 23d. 

Physical Examination. Her face looked a little pinched, 



86 CASE HISTORIES IN PEDIATRICS. 

but she was bright and happy. She was not vomiting and 
had no pain whatever. The pupils were equal and reacted to 
light and accommodation. There was no rigidity of the neck. 
The ears were normal. The heart and lungs showed nothing 
abnormal. The level of the abdomen was considerably below 
that of the thorax. When very deep pressure was made in 
the right iliac fossa she said that it hurt her a little, but gave 
no evidence of pain unless questioned. In fact, she smiled 
and talked while the abdomen was being examined. There 
was also very slight muscular spasm in the right iliac fossa. 
No tumor could be felt and there was no dullness. The ab- 
domen was otherwise negative. The liver and spleen were 
not palpable or enlarged to percussion. The extremities 
showed nothing abnormal. There was no Kernig's sign. 
The knee-jerks were equal and lively. The temperature in 
the mouth was ioi° F., and the pulse 120. 

Diagnosis. The diagnosis in this case lies between tubercu- 
lar meningitis, acute duodenal indigestion and appendicitis. 

Tubercular meningitis should be thought of in this instance 
as in every illness in a child beginning with vomiting. It can 
be ruled out at once, however, on the absence of all signs of 
meningeal irritation and the presence of signs of trouble in 
the abdomen. The white count is also against tubercular 
meningitis, but does not rule it out, as there may be a leuco- 
cytosis in tubercular meningitis. 

The points in favor of acute duodenal indigestion are the 
previous history of attacks of duodenal indigestion and of 
feeble digestion in the past, the typical onset of the attack with 
vomiting of bile, the low temperature and the slightness of 
the physical signs of appendicitis. The points in favor of 
appendicitis are the persistence of the symptoms after proper 
treatment for duodenal indigestion, the pinched face, the 
chill, the leucocytosis and the physical signs, namely, localized 
muscular spasm in the right lower abdomen and the slight 
tenderness in this region on deep pressure. The persistence 
of the symptoms in spite of treatment is merely suggestive 
of appendicitis and not inconsistent with duodenal indigestion. 
The chill is very suggestive of appendicitis, but chills do 
sometimes occur in duodenal indigestion. A leucocytosis as 



DISEASES OF GASTRO-ENTERIC TRACT. 87 

high as 26,200 practically never occurs in duodenal indigestion 
at this age, and in connection with the chill and the physical 
signs is extremely important in the diagnosis. The localized 
muscular spasm is almost pathognomonic of appendicitis 
when taken in connection with the other symptoms and signs. 
The deep tenderness is corroborative evidence of that fur- 
nished by the muscular spasm. It might be thought that the 
physical signs were too indefinite to be of much importance. 
This is not so, however, as indefiniteness of the physical signs 
is characteristic of appendicitis in childhood. Finally, the 
previous attacks which were called duodenal indigestion 
may equally well have been recurrent attacks of appendicitis. 
The diagnosis of Appendicitis, therefore, seems positive. 

The condition of the appendix is always problematical. 
In this instance it is justifiable to conclude from the good 
general condition, the high white count and the mildness of 
the physical signs that perforation has certainly not occurred 
and that in all probability there is but little extension of the 
inflammation outside of the appendix. The appendix, how- 
ever, may very possibly be ulcerated and ready to perforate. 

Prognosis and Treatment. The prognosis is always more 
uncertain in childhood than in later life because of the 
greater difficulty in determining the exact condition of the 
appendix before operation. There is no question but that an 
immediate operation should be done in this instance. She 
is in good condition to bear an operation and, since it is im- 
possible to find out the exact condition of the appendix, it 
is far wiser to operate at once than to run the risk of extension 
of the inflammation or perforation. The prognosis with 
immediate operation is very good because the appendix has 
almost certainly not perforated and there is probably but 
little inflammation about it. 



88 CASE HISTORIES IN PEDIATRICS. 

CASE 2J. Ethel H., four years old, was the extremely 
nervous child of nervous parents. She had always been well 
except for measles and chicken-pox. She vomited a little the 
morning of August 6, but seemed well in every way the next 
day. The following day, which was extremely hot, she went 
to Revere Beach and ate a considerable amount of ice cream. 
She slept fairly well that night, but on the morning of the 
9th vomited once and began to complain of pain about the 
navel. A physician, who was called, found the temperature 
102° F. The respiration was rapid, but the lungs were normal. 
He gave two teaspoonfuls of castor oil and stopped all food. 
She had three or four loose, foul movements, which contained 
a little mucus, but no blood, as the result of the castor oil. The 
abdominal pain continued and was very severe. The tempera- 
ture the morning of the ioth was 103.5 F. The bowels 
moved three times during that day, the movements being of 
the same character. The abdominal pain continued. The 
evening temperature was 101 F. The pulse ranged between 
145 and 160, and the respiration between 40 and 80. There 
was no cough and the lungs remained normal. She vomited 
several times that night and, on account of the severe pain 
in the abdomen, slept but little. The temperature by rectum 
the morning of the nth was 99. 6° F., the pulse 140. She 
took no food, but drank considerable water. She vomited 
several times that morning. She had had a little brandy, 
some bismuth and chalk mixture and two doses of Castoria. 
She was very restless and complained constantly of pain in 
the abdomen. The abdomen was distended and tender from 
the first, the physician thought less so that morning. The 
physician had felt that the pain was exaggerated because 
of the nervous temperament of the child. She was seen in 
consultation at noon, August n. 

Physical Examination. She was well-developed and fairly 
nourished. There was moderate pallor. She was very rest- 
less, tossing from side to side and constantly crying out from 
pain in the abdomen. She lay on her back w T ith the legs 
flexed on the abdomen; extending them caused pain. Her 
face looked pinched. The tongue was dry, but not coated. 
The heart and lungs were normal. The abdomen was only 



DISEASES OF GASTRO-ENTERIC TRACT. 89 

moderately enlarged, but very tense. No localized spasm 
could be made out. She complained whenever the abdomen 
was touched, but no more so on deep than on light pressure. 
There was no localized tenderness. There were no signs of 
fluid in the abdomen. The liver and spleen were not palpable. 
Rectal examination showed nothing abnormal, but caused 
much pain. The extremities were normal. There was no 
spasm or paralysis. The knee-jerks and Kernig's sign could 
not be obtained because of the child's resistance. The rectal 
temperature was ioi°F. ; the pulse, 156. A movement, 
passed during the examination, consisted of a few small 
masses of brownish mucus. 

Diagnosis. Pneumonia is suggested by the sudden onset 
and the comparatively greater rise in the rate of the respira- 
tion over that of the pulse. The location of the pain in the 
abdomen is not against pneumonia, because the pain in 
pneumonia in childhood is often localized in the abdomen. 
The abdomen is also often tense in the early stages of pneu- 
monia in childhood. The drop in the temperature without a 
corresponding diminution in the rate of the respiration, the 
absence of cough, grunting respiration and movement of the 
alse nasi, the absence of physical signs in the lungs and 
the pinched face are together sufficient to exclude pneumonia. 

The free movements of the bowels are sufficient to rule out 
intestinal obstruction. 

The diagnosis lies, therefore, between intestinal toxemia 
and appendicitis. The history of eating ice cream on a hot 
day is suggestive of intestinal toxemia, but is not inconsistent 
with appendicitis. The continuance of the symptoms in 
spite of catharsis and starvation is against toxemia, but does 
not exclude it. The character of the stools is much against 
toxemia. The vomiting is consistent with either condition 
and hence is of no importance in the differential diagnosis. 
Distention of the abdomen is, however, unusual in toxemia, 
and tenderness and pain extremely rare. These two points 
are sufficient in themselves to turn the scale in favor of 
appendicitis. 

The general abdominal distention accounts for the lack of 
localized spasm and tenderness and suggests a beginning or 



90 CASE HISTORIES IN PEDIATRICS. 

developing general peritonitis. The drop in the temperature 
with no improvement in the other symptoms is strong evi- 
dence that perforation has occurred and peritonitis begun. 
The diagnosis is, therefore, Appendicitis with probable 
perforation and beginning peritonitis. 

An examination of the blood was not made in this instance 
and would not have helped, because a high white count is 
consistent with either condition. Moreover, a low white 
count is consistent with either depression after perforation 
or intense toxemia. 

Prognosis and Treatment. The prognosis in this instance 
is practically hopeless. The only chance lies in immediate 
operation. 



DISEASES OF GASTRO-ENTERIC TRACT. 9 1 

CASE 28. Nathaniel C, three years old, had always been 
very well and strong. There had been no indiscretion in 
diet. The milk supply was supposedly above reproach; his 
surroundings were ideal. He complained of indefinite pains 
in the legs and abdomen during the day of November 19, but 
was up and dressed. His nurse gave him some castor oil in 
the morning. When seen by his physician at 3 p.m. the physi- 
cal examination was entirely negative; the temperature, 
1 00. 5 F. He began to have loose movements during the 
night, which were not carefully observed. The morning of 
the 20th the movements were very foul and began to contain 
slight streaks of blood. He did not seem really sick. The 
rectal temperature was 99 F. He had six movements con- 
taining blood and mucus during the day of the 20th. Part 
of them were foul, the others were not. He was given bis- 
muth during the day and his bowels were irrigated in the 
evening. He had six more movements of the same character 
during the night. He had eight similar movements during the 
day, which were preceded and followed by pain. He had been 
nauseated for the first time during the afternoon, but had not 
vomited. He had had nothing but water during the day, but 
had taken a mixture of bismuth and salol with ten drops of 
paregoric every two hours. He was seen in consultation at 
7 p.m., November 21. 

Physical Examination. He was well developed and nour- 
ished and of good color. He was perfectly intelligent. The 
tongue was moist and but slightly coated. The heart and 
lungs were normal. The abdomen was sunken and negative, 
except that he complained of slight pain on deep pressure in 
the left lower quadrant. Nothing else abnormal was made 
out. The liver and spleen were not palpable. The extremi- 
ties were normal. There was no spasm or paralysis ; the knee- 
jerks were equal and normal; Kernig's sign and the neck 
sign were absent. There was no enlargement of the peripheral 
lymph nodes. Rectal examination showed nothing abnormal. 
The rectal temperature was ioo°F.; the pulse, 160. 

The movements were small and composed almost entirely 
of green mucus and blood. 

Diagnosis. The continued moderate temperature and the 



92 CASE HISTORIES IN PEDIATRICS. 

small movements of mucus and blood associated with pain 
are so charactertisic of Infectious Diarrhea of the dysen- 
teric type that no differential diagnosis from the other forms 
of diarrhea is necessary. The only other possibility, intus- 
susception, can be ruled out on the slow onset, the absence of 
vomiting and the negative abdominal and rectal examinations. 

Prognosis. Infectious diarrhea of this type is always a 
serious disease. The patient is not out of danger until he is 
well. It is impossible to say so early in the disease as this 
what course it may take. The relatively low temperature, the 
comparatively small number of movements, the absence of 
vomiting, the nearly clean tongue and the good general con- 
dition make the prognosis in this instance comparatively 
good. The chances at present seem to be about three out of 
five in favor of recovery. 

Treatment. It is doubtful if he has been thoroughly cleaned 
out. A tablespoonful of castor oil is, therefore, indicated. 
It will probably be wiser to continue the starvation for twenty- 
four hours longer. He must, however, have a sufficient supply 
of water. This is, for a boy of his age, about a quart in twenty- 
four hours. If he will not take it by mouth, it may be given 
high in the bowel by the drop method. His condition at 
present is hardly serious enough to warrant the use of salt 
solution subcutaneously. It will probably be wise to begin 
nourishment after twenty-four hours. Milk in any form is 
contra-indicated. Starches, such as barley, arrowroot or 
rice, in the form of waters or jellies, either with or without 
milk sugar or malt sugar to increase their nutritive value, will 
be best borne. If he will not take starches in this form there 
is no objection to giving them in the form of crackers, zwie- 
bach or toast. Weak mutton or chicken broth may be given, 
not as foods (because they are practically without nutritive 
value), but to induce him to take the starchy foods and as a 
means of introducing water. Beef juice is contra-indicated 
because it is so prone to decomposition by the intestinal 
bacteria. Albumen water is likely to produce urticaria and 
has but little nutritive value, the white of an egg containing 
but twelve calories. A few ounces of albumin water, made as 
it usually is with the white of one egg to eight ounces of water, 



DISEASES OF GASTROENTERIC TRACT. 93 

has, therefore, practically no nutritive value. It is, like beef 
juice, prone to decomposition by the intestinal bacteria. It 
is, therefore, contra-indicated. 

Irrigation of the bowels once or twice in the twenty-four 
hours with physiological salt solution, or a i% solution of 
boracic acid, is indicated to cleanse the colon. It has no 
direct healing action. The irrigation should be given with a 
soft rubber catheter, No. 25 French, passed as high as possible 
into the bowel, with the patient lying on the back with the 
hips elevated. The fluid is then allowed to run in from a bag 
hung not more than two feet above the level of the patient. 
It should be allowed to run in until the abdomen is slightly 
distended, then allowed to run out, and so on, until the wash 
water returns clean. The object of the irrigation is to cleanse 
the colon. Enough liquid should be used to do this, no matter 
whether it is much or little. Irrigation should never be done 
more than twice in the twenty-four hours. If it depresses or 
disturbs the patient much, it should be omitted, as under 
these conditions it does more harm than good. 

Bismuth, salol and other preparations of like nature have, 
in the author's opinion, little or no effect on infectious 
diarrhea. It disturbs the patient to take them and interferes 
with the administration of food and water. It will be wiser, 
therefore, not to give them in this instance. Paregoric and 
other preparations of opium are, on general principles, contra- 
indicated in all forms of diarrhea, because their action is to 
diminish the number of movements by depressing peristalsis 
and not by relieving the cause of the increased peristalsis. 
The increased peristalsis is nature's effort to get rid of the 
poisonous intestinal contents. Nature's effort should, there- 
fore, not be interfered with. In infectious diarrhea of the 
dysenteric type, however, when there is a very large number 
of small movements accompanied by pain and tenesmus 
which prevent the patient from getting proper rest, it is 
allowable to give opium in some form to diminish the excessive 
peristalsis and to quiet the patient. There is no danger, if 
proper care is used, of doing harm by retaining the intestinal 
contents too long. Paregoric, in doses of ten or fifteen drops, 
may be given in this instance, therefore, if necessary. 



94 CASE HISTORIES IN PEDIATRICS. 

CASE 29. Pearl P., one year old, had always been well. 
She was fed on raw, unmodified cow's milk. She had had some 
slight disturbance of the bowels about the middle of Ju!y, 
but had almost entirely recovered. She suddenly began to 
vomit about noon, July 28. The vomitus consisted at first 
of milk, but soon became watery; it did not contain bile. 
Diarrhea came on in a few hours. The movements were at 
first fecal in character, but soon became watery and colorless. 
She vomited and had a movement every few minutes. Thirst 
became marked, but everything taken was vomited. Castor 
oil and calomel were also vomited. Her temperature that 
night was 104 F. The next morning she was much collapsed. 
She was seen in consultation at 9 a.m., twenty-one hours after 
the onset. 

Physical Examination. She had evidently lost much weight. 
Her skin was dry and her extremities cold and blue. The 
fontanelle was much depressed. Her eyes were wide open and 
staring, but she took very little notice. The pupils were 
equal and reacted to light. Her tongue was dry. She held 
her head rigidly backward. The heart and lungs were normal. 
The abdomen was much sunken but not rigid. Neither liver 
nor spleen were palpable. She tossed her arms about con- 
stantly. Her legs were somewhat rigid ; the knee-jerks were 
equal and exaggerated; Kernig's sign could not be determined 
because of the rigidity. The rectal temperature was 104 F., 
the pulse 160, and the respiration 60. The vomitus and move- 
ments looked like turbid water. 

Diagnosis. The history and physical examination are so 
typical of Cholera Infantum that there is no need of con- 
sidering any other disease. The nervous symptoms are due 
to a combination of toxemia and loss of fluid. 

Prognosis. The prognosis is very grave. There is probably 
not more than one chance in twenty of recovery. The 
disease is, however, to a certain extent, self-limited. If she 
lives through the next thirty-six hours the chances of recovery 
will be very much better. 

Treatment. The main indications for treatment in this 
condition are (1) to empty the stomach and bowels of their 
toxic contents; (2) to supply fluid to the tissues which are 



DISEASES OF GASTRO-ENTERIC TRACT. 95 

being so seriously drained ; (3) to restore the surface circula- 
tion; (4) to reduce the temperature; (5) to keep the patient 
alive until the disease has run its course. 

Nature is already doing her best to empty the stomach and 
bowels. Nothing can be done to help her. Cathartics will be 
vomited and stomach washing and irrigation of the bowels 
will only increase the collapse. There is no objection, how- 
ever, to giving the baby cool water to drink, even if it is 
vomited, as it will make her more comfortable and help to 
wash out the stomach. 

The only way in which fluid can be supplied to the tissues 
is by the administration of physiological salt solution subcu- 
taneously. She should be given from four to eight ounces at 
a time, repeated every three or four hours if absorbed. 

The surface circulation is best restored by the application 
of heat externally in the form of heaters or hot packs. She 
should be at once surrounded with heaters and, if this is not 
successful, be put in a pack at ioo° F., or a little higher. 
Restoration of the surface circulation will usually reduce the 
internal temperature. If it does not, irrigation of the colon 
with water at 90 F. will usually do so. Her temperature is 
hardly high enough to require this at present. 

It is useless to give stimulants or other drugs by the mouth, 
as they will not be retained. All drugs must, therefore, be 
given subcutaneously. The best stimulant is caffein. This 
may be given subcutaneously in the form of caffeine-sodium 
benzoate. The dose for this baby is one quarter of a grain 
every three or four hours. Strychnia, in doses of 1-500 of a 
grain, may also be given subcutaneously, if necessary. Alcohol 
is contra-indicated. Adrenalin is indicated if the cardiac 
failure increases. Unfortunately it has very little action when 
given subcutaneously, and intravenous injection is very 
difficult in a baby of this age. If the restlessness increases, 
morphia, in doses of 1-100 of a grain, given subcutaneously, 
will aid by quieting her and saving her strength. 

Food of any description is contra-indicated until the vomit- 
ing and diarrhea have stopped. The first food given should 
be a 1% solution of starch in the form of barley water, with 
5% of milk sugar added. 



SECTION III. 
DISEASES OF NUTRITION. 

CASE 30. Cynthia M., the first child of healthy parents, 
was born at full term after a normal labor, and weighed 
ten and one-fourth pounds. The breast-milk gave out after 
two weeks and she was put on a rather strong modification 
of milk, on which, nevertheless, she did fairly well. She 
began to vomit when two months old and the gain in weight 
became very slow, but the movements remained normal. 
When four months old she was put on a home modified milk 
which contained about 2% of fat, 9.60% of sugar, 0.75% of 
whey proteids and 0.40% of casein. She had seven feedings 
of six ounces. She vomited less while taking this mixture, 
but continued to regurgitate. She had one normal move- 
ment daily, but her weight remained stationary. She had 
some colic. The sugar in the mixture was reduced to 6% 
and the vomiting and colic became less. When five months 
old, as she did not gain, she was changed to a home modified 
mixture which contained about 1.80% of fat, 10% of sugar, 
0.90% of proteids and 0.50% of starch. She took seven feed- 
ings of six ounces. She was not at all satisfied, vomited less 
than before and had very little colic, but was somewhat 
constipated. The movements were normal in character. 
She held her weight the first week, but lost half a pound the 
second week. She was then seen, when six months old. She 
slept well, had plenty of fresh air and did not act sick. 

Physical Examination. She was fairly developed and 
nourished. Her color was good. She was a little flabby. 
The fontanelle was level. The mouth was healthy and the 
tongue clean. She had one tooth. There was a very slight 
rosary. The heart and lungs were normal. The level of the 
abdomen w T as that of the thorax, and nothing abnormal was 
detected in it. The liver was palpable 1 cm. below the costal 

97 



98 CASE HISTORIES IN PEDIATRICS. 

border in the nipple line. The spleen was not palpable. 
The extremities were normal. There was no spasm or paraly- 
sis; the knee-jerks were equal and normal; Kernig's sign was 
absent. There was no enlargement of the peripheral lymph 
nodes. She weighed thirteen pounds. 

The movement was yellow and salve-like in consistency, 
except in one place where it was a little granular and brittle. 
The odor was slight. The reaction was alkaline (presumably 
from the relatively large amount of proteid in relation to the 
fat). Microscopically it showed no undigested fat, starch or 
casein. 

Diagnosis. The physical examination shows nothing ab- 
normal except flabbiness and a slight rosary. The former is, 
of course, merely a sign of malnutrition. The rosary means 
rickets, but when it is slight and the only bony sign of the 
disease, as in this instance, the rickets is of practically no 
importance and need not be considered. The very slight 
amount of the vomiting and the normal movements show that 
there can be no disturbance of digestion sufficient to account 
for the loss of weight. The evident hunger and the tendency 
to constipation point strongly to an insufficient supply of 
food as the cause. Whether this is so or not can, of course, 
be determined practically by giving more food and awaiting 
the result. Proceeding in this way, however, there is no guide 
as to how much more food should be given. It is far better 
to calculate the caloric value of the food and thus know the 
truth at once, and, if the baby is under-fed, know how much 
so, and also how much more food to give. 

A baby of six months requires, on the average, about ioo 
calories per kilo daily in order to thrive and gain. This baby 
weighs 5.9 kilos and, therefore, needs about 600 calories 
daily. It is not a difficult matter to calculate the caloric 
value of the food. Forty- two ounces equals 1,260 ccm.; 
1.8% of fat equals 1.8 grams of fat in 100 ccm. of food, or 22.6 
grams in 1,260 ccm. The caloric value of I gram of fat is 
9.3 calories. The caloric value of the fat in the food is, there- 
fore, 210 calories. The caloric value of proteid, sugar and 
starch being the same, 4.1 calories per gram, they can be 
calculated together. Figuring in the same way as for the fat, 



DISEASES OF NUTRITION. 99 

they together furnish 129 calories. The total value of the 
food is, then, 339 calories or 57 calories per kilo, only a little 
more than half the caloric needs. 

A baby must not only get a certain number of calories 
daily in its food, but it must also get at least 1.5 grams of 
proteid per kilo in order to thrive. It will gradually fail and 
die if the proteids are insufficient, even if the food contains a 
sufficient number of calories. This baby's food contained 
0.9% of proteid or 11.3 grams in the 42 ounces. This is equal 
to 1.9 grams of proteid per kilo and amply covers the proteid 
needs. This ample supply of proteids explains her good 
general condition and the fact that she has not appeared 
sick. 

The diagnosis is, therefore, Malnutrition from an In- 
sufficient Supply of Food. The knowledge that the caloric 
value of the food is insufficient also enables us to rule out 
infantile atrophy, a condition in which there is a progressive 
loss of weight, while the caloric value of the food is normal 
and there are no symptoms of indigestion. 

Prognosis. The prognosis is, of course, perfectly good if 
the caloric value of the food is increased. There seems to be 
no reason why it cannot be in this instance as the stools show 
that all the components of the food are digested. 

Treatment. The best food for infants, whether sick or well, 
is human milk. A wet nurse is, therefore, the best treatment 
for this patient. A wet nurse is not necessary in this instance, 
however, as the baby can undoubtedly be easily fed on some 
modification of cow's milk. 

Past experience shows that it will not be wise to give this 
baby over six per cent of sugar. It is advisable to keep the fat 
down when babies vomit. It will, therefore, be wise to keep 
the percentage of fat as low as is consistent with meeting the 
caloric needs. There is no objection to giving a reasonably 
high percentage of proteids, as the baby has already shown 
her ability to digest them. It will be wise to continue the 
starch in the mixture, since the examination of the stools 
shows that the baby can digest it and it adds to the caloric 
value of the food. Six feedings of five and one-half ounces 
each ought to be about right for her age and weight. 



IOO CASE HISTORIES IN PEDIATRICS. 

The following formula meets these indications and covers 
both the caloric and proteid needs: 

Fat, 2.50% 

Sugar, 6.00% 

Proteids, 1.50% 

Starch, 0.75% 

Six feedings of 5J ounces give 565 calories, or 96 calories 
per kilo, and 14.8 grams of proteid, or 2.5 grams of proteid per 
kilo. 

Approximately the same mixture can be prepared at home 
as follows: 

Gravity cream (16%), 5 ounces 
Skimmed milk, 10 ounces 

Barley water (1.50% 

starch), 18 ounces 

Milk sugar, 2 rounded and 1 level 

tablespoonful 

Two teaspoonfuls of barley flour to a pint of water makes a 
1.50% starch solution. One rounded tablespoonful of milk 
sugar is equal to about half an ounce. 

No drugs are indicated. 



DISEASES OF NUTRITION. 1 01 

CASE 31. David W., was born at full term and was the 
only child of healthy parents. There was no history of tuber- 
culosis in the family and no known exposure to it. He weighed 
nine pounds at birth, but fell to six pounds in the first three 
weeks, and when seen in consultation at eleven months 
weighed but ten pounds. He had always been fed on milk, 
prepared in various ways. During the first month the mixture 
had been sterilized. This apparently upset the baby and 
caused considerable constipation. A little later he was given 
one part of whole milk to three of water, but as the move- 
ments contained curds, the strength was reduced to one part 
of whole milk to six of water. As he still passed curds, he 
was given a condensed milk mixture, containing one part of 
condensed milk to twelve of water. As he did not gain and 
continued to have curds in the stools, he was given a modified 
milk mixture prepared at a laboratory. He was at first given 
straight proteids of one per cent; later, part of the proteids 
were given in the form of whey proteids. He did better on 
this, but the movements still contained curds. This was 
stopped after a few months and he was put on condensed 
milk again. As he did not gain, he was put back on modified 
milk. During the last month he had been taking six feedings 
of 5! ounces of a mixture containing 2.75% of fat, 6.00% of 
sugar and 0.25% of proteids, but was not gaining. 

He had been constipated during all this time, except for 
two short attacks of diarrhea a month or two before he was 
seen. He had always taken his food well and had almost 
never vomited. The movements had always been fairly well 
digested, except that they at times contained a few curds. 
He was a quiet baby and almost never fussed. 

Physical Examination. He was small and poorly nourished. 
Pallor was marked. The skin was somewhat dry. The 
anterior fontanelle was 2 cm. in diameter, the level being 
somewhat below that of the surrounding bones. He had two 
lower incisors. There was no rosary. The heart and lungs 
were normal. The level of the abdomen was below that of 
the thorax; it was lax, easily palpable and showed nothing 
abnormal. The liver was palpable 2 cm. below the costal 
border in the nipple line; the spleen was not palpable. The 



102 CASE HISTORIES IN PEDIATRICS. 

extremities showed nothing abnormal. There was no spasm 
or paralysis; the knee-jerks were equal and normal. There 
was a slight general enlargement of the superficial lymph 
nodes. The weight was ten and one-half pounds. 

Diagnosis. The examination shows nothing except mal- 
nutrition. It gives no clue as to its cause. This must be 
sought in the history. In general, the causes of malnutrition 
which give no physical signs beyond those of malnutrition 
are congenital syphilis, chronic diffuse tuberculosis, infantile 
atrophy, chronic indigestion and starvation. 

Disturbance of nutrition is the main symptom in some 
cases of congenital syphilis. The good family history, the 
absence of any other signs of syphilis and the presence of 
other causes for the malnutrition rule it out in this instance. 
The slight general enlargement of the superficial lymph nodes 
does not point either to syphilis or tuberculosis. It is com- 
mon to all disturbances of nutrition in infancy and is, conse- 
quently, of no diagnostic value. Chronic diffuse tuberculosis, 
meaning by this term the condition in which there are 
numerous tubercular foci scattered throughout the body, 
larger and older than the miliary tubercle, but not large enough 
or so situated as to give physical signs, is not very infre- 
quent in infancy. It cannot be recognized on physical exam- 
ination, but only by the tuberculin test. It cannot be ruled 
out in this instance, but is less probable than some other 
conditions. The symptoms of indigestion are not suffi- 
cient to account for the malnutrition. 

Barring chronic diffuse tuberculosis, which can only be 
positively excluded by a tuberculin test, the diagnosis lies, 
therefore, between infantile atrophy and starvation. The 
term, " infantile atrophy," should be limited to those cases 
in which there is a progressive loss of weight in spite of a 
sufficient intake of food, there being at the same time no 
symptoms of disturbance of the digestion. In this class of 
cases there is presumably some obscure disturbance of absorp- 
tion or metabolism. Clinically they form a very definite 
group. It is probable, however, that, with the increase of our 
knowledge of chemical pathology, they will, in the future, be 
classified in some other way. 



DISEASES OF NUTRITION. IO3 

While he was taking the condensed milk and whole milk 
mixtures he was unquestionably not getting enough calories, 
but in the last mixture he got 105 calories per kilo, or just 
about enough to cover his caloric needs. A baby cannot 
thrive, however, even if the food contains a sufficient number 
of calories, if it does not also contain proteids enough to 
cover the proteid needs. The condensed milk and whole 
milk mixtures contained, respectively, 0.66%, 0.87% and 
0.50% of proteids, which were probably not quite enough to 
meet the proteid needs. His last mixture gave but 0.5 
grams of proteid per kilo, while he needed at least 1.5 grams 
of proteid per kilo. The diagnosis of infantile atrophy is, 
therefore, not justified because, while he is getting a sufficient 
number of calories, he is not getting enough proteid, and the 
condition is best called Malnutrition from an Insufficient 
Amount of Proteid in the Food. If he does not begin to 
gain weight when the proteid is increased enough to cover his 
proteid needs, the diagnosis will have to be changed to 
infantile atrophy, which has probably developed as the 
result of the continued insufficient supply of proteids. 

Prognosis. The prognosis must be held in abeyance until 
the effect of an increase in the proteids is known. If he begins 
to gain when they are increased, the prognosis is good; if he 
docs not, it is very grave unless he is given human milk. If 
he gets this he will probably recover, because babies with 
atrophy can usually utilize the proteids of human milk even if 
they cannot those of cow's milk. 

Treatment. The treatment consists in the regulation of 
the food. Human milk is altogether the best food for him. 
It will almost certainly cure him whether the condition is 
proteid starvation or atrophy. If he cannot get this, the next 
best thing is some modification of cow's milk. He is digesting 
the present mixture, which, however, does not contain enough 
proteid. The natural thing to do, therefore, is to leave the 
percentages of fat and sugar unchanged and to increase the 
proteids to 0.75% in order to cover his proteid needs, keeping 
the number and amount of the feedings the same. There is 
no indication for medicinal treatment. 



104 CASE HISTORIES IN PEDIATRICS. 

CASE 32. George T. was the only child of healthy par- 
ents. He was born two months before he was expected. He 
had never been nursed, but had been fed on whole cow's milk, 
more or less diluted with water. He had never done well. 
He vomited at times directly after feeding, but never between 
feedings. His bowels were constipated ; the movements were 
smooth. His head sweat a great deal. He was fussy and slept 
poorly. He was brought to the hospital when eleven months 
old. ' 

Physical Examination. He was small and thin, weighing 
but nine pounds. Pallor was marked. He could hold up his 
head, but was unable to sit alone. When supported he sat 
with a marked general kyphosis. This disappeared when he 
lay on his face. The frontal and parietal eminences were so 
much enlarged that the top of the head showed a depression 
between them both longitudinally and across.. The anterior 
fontanelle was 5 cm. in diameter and depressed. There was 
no craniotabes. The pupils were equal and reacted to light. 
There were no teeth. The mouth and throat were normal. 
There was a marked rosary and there was a depression around 
the lower part of the chest at the level of the insertion of the 
diaphragm, with moderate flaring of the ribs below. The 
heart and lungs were normal. The liver was palpable 3 cm. 
below the costal border in the nipple line ; the spleen was not 
palpable. The extremities showed nothing abnormal except 
a moderate enlargement of the epiphyses at the wrists and 
ankles. There was no spasm or paralysis; the knee-jerks 
were equal and normal. There was a moderate general en- 
largement of the peripheral lymph nodes. There was no 
eruption. 

The urine was pale, slightly acid, of a specific gravity of 
1,010 and contained no albumin. 



Blood. 




Hemoglobin, 


25% 


Red corpuscles, 


2,566,000 


White corpuscles, 


15,000 


Small mononuclears, 


62% 


Large mononuclears, 


3% 


Polynuclear neutrophiles, 


34% 


Eosinophiles, 


1% 



DISEASES OF NUTRITION. 



105 



There was moderate variation in the size, but none in the 
shape or staining reaction, of the red corpuscles. No nucleated 
forms were seen. 

Diagnosis. The diagnosis is, of course, Rickets and 
Secondary Anemia. The enlargement of the frontal and 




Fig. 4. George T. Case 32. 



parietal eminences with the resultant " square " head, the 
rosary and the enlargement of the epiphyses at the wrists and 
ankles are pathognomonic of rickets. The weakness of the 
back, the large anterior fontanelle, the absence of teeth and 
the deformity of the chest are, in this instance, undoubtedly 
also signs of rickets, but are not pathognomonic, as they may 
be caused by other conditions. 

The rachitic enlargement of the head, so well shown in this 
baby, is not infrequently mistaken for hydrocephalus. There 
should not, however, be any difficulty in distinguishing be- 
tween them. The enlargement of the rachitic head is due to 
the overgrowth of bone on the outside; that of the hydroce- 
phalic head to increased pressure on the inside. The rachitic 
head is asymmetrical and flattened on top ; the hydrocephalic, 
symmetrical and rounded. In the former the fontanelle is 
level or sunken; in the latter, bulging. In rickets the eyes 
appear normal; in hydrocephalus, they are prominent. 
These differences are well shown in the accompanying photo- 
graphs. 

The kyphosis seen in this instance is often mistaken for the 



106 CASE HISTORIES IN PEDIATRICS. 

deformity of Pott's disease. The diagnosis between them is, 
however, a simple one. The deformity in rickets is due to 
muscular weakness, is a general rounded curve, involving the 
whole spine, and disappears on extension. That in Pott's 
disease is due to deformity of the bone, is a local angular 
protuberance, involving only part of the spine, and does not 
disappear on extension. This curve is well shown in the ac- 
companying photograph of a baby of about the same age as 
the patient. 

The blood picture is that of a secondary anemia of a moder- 
ate grade. The percentage of hemoglobin is relatively lower 
than the number of red corpuscles. This " chlorotic " type 




Fig. 5. Curve of Weakness. Case 32. 

of blood is characteristic of the secondary anemias of infancy. 
The white count is so little above the normal that it can hardly 
be called a leucocytosis, especially as the differential count of 
the white cells is normal for this age. The anemia should not 
be regarded as a symptom of the rickets, but merely as 
another manifestation of the same disturbance of nutrition 
which caused the rickets. 

Prognosis. The prognosis as to life is good. The activity 
of the rachitic process will quickly cease under proper treat- 
ment, but the bony deformities will still remain. The rosary 
and enlargement of the epiphyses will disappear in a year or 
two. The deformity of the chest will probably never entirely 
disappear, and his head will probably always be a little large 



DISEASES OF NUTRITION. I OJ 

and peculiarly shaped, but not enough so to attract any 
attention. 

Treatment. The treatment is hygienic and dietetic, not 
medicinal. He should be given the maximum amount of 
fresh air and sunlight and especially protected against all 
sorts of contagion. 

There are no special indications as to the regulation of his 
diet, except that he has not done well on the combination of 
low fat and sugar with high proteids, which he has had in the 
past. A reasonable mixture for him is: 

Fat, 3.50% 

Sugar, 7-00% 

Proteids, 1.50% 

Starch, 0.75% 

An alkali is not indicated in this instance as there has been 
no disturbance of the gastric digestion. Six feedings of six 
ounces is sufficient for his weight. If the constipation con- 
tinues on this mixture, he may have from one-half to two 
tablespoonfuls of orange juice daily. 

The saccharated carbonate of iron in three-grain doses, or 
ferratin in two-grain doses, will help the anemia. The author 
has not seen any better results when cod-liver oil and phos- 
phorus have been given in addition to regulation of the diet 
and hygienic surroundings than when they have not, and 
consequently seldom prescribes them. 



108 CASE HISTORIES IN PEDIATRICS. 

CASE 33. Pauline P. was born July 15 at full term after 
an instrumental labor, was normal at birth and weighed 
eight pounds. Her father learned, about July 1, that he had 
pulmonary tuberculosis and went West about two weeks 
after she was born. She was put at once on modified milk 
and did very well. About October 1, when ten weeks old, she 
went West and joined her father. He slept out of doors and 
was very careful not to expose her to infection. After going 
West she was fed on equal parts of whole milk and water, 
prepared with Mellin's Food. This did not agree with her 
very well. She returned to her home in the East, February 1, 
having been with her father about four months. She was 
then put on a mixture of whole milk and water, prepared with 
" Peptogenic Milk Powder." In the course of the preparation 
of the food, the milk was brought to a boil. She had been 
taking this food for three and one-half months when she was 
seen. She had taken and digested it well and gained steadily 
in weight. 

She stopped creeping about April 20. April 26 she fell out 
of a low chair to the floor, striking on her forehead. She did 
not seem hurt, except for a bruise on the right side of the 
forehead. Beginning with the next day she cried a great 
deal during her bath, and May 1 it was noticed that motions 
of the legs caused pain. The pain on motion of the legs 
increased. She lay on her back and kept her legs drawn up. 
When quiet in this position she had no pain. She was very 
much afraid of being touched and began to cry when any one 
approached her. The upper gums became inflamed about 
May 10. Her appetite had fallen off and she had lost some 
weight and much color since the appearance of the pain, 
although she had shown no signs of indigestion. Her tempera- 
ture had not been taken, but she had not appeared feverish. 
The urine had not stained the diapers. She was seen in con- 
sultation May 17, when ten months old. 

Physical Examination. She was fairly developed and nour- 
ished and moderately pale. ■ She was very much afraid of 
being touched. The fontanelle was level. There was an 
ecchymosis, about the size of a five-cent piece, on the right 
side of the forehead. The two lower central incisors had 



DISEASES OF NUTRITION. 1 09 

erupted and the gum was normal about them. The upper 
gum was distended by the four incisors. The gum was a 
little purplish over them. The tongue was clean and the 
throat normal. There was a slight rosary. The heart, lungs 
and abdomen were normal. The liver was palpable 2 cm. 
below the costal border in the nipple line; the spleen was not 
palpable. The spine was perfectly flexible. She preferred to 
lie on her back with the legs flexed at the hips and knees. 
Neither active nor passive motions were limited, but motions 
at the hips and knees caused much pain. There was no 
definite tenderness and no swelling about the bones or joints. 
The arms were not tender and were used freely without dis- 
comfort. The knee-jerks were equal and normal; Kernig's 
sign was absent; sensation to touch and pain was normal. 
There was no enlargement of the peripheral lymph nodes. 
The rectal temperature was 98. 6° F. 

Diagnosis. Tuberculosis of the spine or hip- joints had been 
seriously considered by the physician in charge because of 
the known exposure to tuberculosis. The normal mobility 
of the spine and at the hips, together with the normal tempera- 
ture, rule this out. The grandmother thought that the fall 
might be the cause of the pain. The baby had, however, 
stopped creeping before the fall and showed no evidence of 
injury at the time. It is hard to conceive, moreover, of an 
injury which would involve both legs and not show any 
physical signs. Infantile paralysis and multiple neuritis 
might be thought of on account of the pain. Infantile paraly- 
sis can be at once excluded because of the absence of paralysis 
and the presence of normal reflexes after three weeks. Multi- 
ple neuritis can be ruled out because at this age it is almost 
always a sequela of diphtheria and, consequently, is seldom 
accompanied by pain. The reflexes are intact, moreover, and 
there is no paralysis or disturbance of sensation. Osteomye- 
litis and periosteitis seldom occur in more than one place at a 
time and can be excluded on the good general condition and 
the absence of fever and localized tenderness. The combina- 
tion of pain without physical signs is characteristic of rheuma- 
tism in early life. Rheumatism almost never occurs in 
early infancy, however, and will not account for the swollen 



110 CASE HISTORIES IN PEDIATRICS. 

and purplish gum. The slow onset, the unwillingness to use 
the legs, the pain on motion and the position in which the 
legs are held are almost pathognomonic of Scurvy and justify 
that diagnosis without any other evidence. The combination 
of these signs with the swollen, purplish gum, another char- 
acteristic sign of scurvy, cannot be accounted for in any other 
way, and makes the diagnosis absolute. The ecchymosis 
on the forehead may be a scorbutic manifestation but, on 
the other hand, may be simply the result of the fall. The 
prolonged use of boiled milk is corroborative evidence of 
the diagnosis of scurvy, as it is undoubtedly one of the causes 
of this disease. 

Prognosis. The prognosis is absolutely good. She will be 
perfectly well in a week if properly treated. 

Treatment. The first step in the treatment is to remove 
the probable cause of the disease, that is, boiling the milk. 
There seems to be no reason for changing the composition of 
the food as she was doing very well on it except for the scurvy. 
The mixture contains 2% of fat, 6.50% of sugar and 1.75% of 
proteids. It is always unwise to continue peptonization over 
long periods because it tends to weaken the digestive power. 
It will, therefore, be wise to replace the " Peptogenic Milk 
Powder " (which is composed largely of milk sugar) by milk 
sugar and to add starch, in the form of barley water, to hinder 
the formation of large curds. The following combination is a 
suitable one: 

Whole milk, 24 ounces 

Barley water (1.50% starch), 24 ounces 
Milk sugar, 4 rounded tablespoonfuls 

This mixture contains 2% of fat, 6.50% of sugar, 1.75% of 
proteids and 0.75% of starch. The sugar should be mixed 
Avith the hot barley water and the mixture cooled before the 
milk is added. She should take six feedings, of from seven 
to eight ounces. 

She will undoubtedly recover in time on the " fresh " food, 
but recovery will be slow. Fruit juices, however, have a 
specific action in infantile scurvy, and should, therefore, 
always be given. They will cure the process even if the cause 
is not removed. Orange juice is the best, because it is the 



DISEASES OF NUTRITION. Ill 

most readily taken. Babies seldom object to it. It may be 
given plain or diluted with water. There is no objection to 
the addition of cane sugar if the orange is sour. It may be 
given all at one dose or divided into two doses. It is best 
given about an hour before a feeding, when the stomach is 
empty. One ounce is the proper dose. Less than this may 
be ineffectual, more is unnecessary. She should have, there- 
fore, an ounce of orange juice daily. This dose should be 
continued until all symptoms of the disease have disappeared. 
It will be wise to keep it up for some time longer, but the dose 
need not be as large. 



112 CASE HISTORIES IN PEDIATRICS. 

CASE 34. Laliah P. was the first child of healthy parents. 
She was born at full term and weighed six and one-half 
pounds. She had always been fed on pasteurized milk 
prepared at a laboratory. She had done very well until she 
was six months old, when she ceased to gain and lost her 
appetite. When she was seven months old her mother noticed 
that the urine at times stained the diapers red. This staining 
was attributed by the physician in charge to uric acid. It 
continued intermittently for a month, when the urine was 
examined and found to contain fresh blood, but no casts. 
Micturition was not increased in frequency and was not 
painful. There were no other symptoms whatever except 
failure to gain in weight. She was seen in consultation when 
eight months old. 

Physical Examination. She was well developed and nour- 
ished, but somewhat pale and flabby. She was bright and 
happy. The anterior fontanelle was 3 cm. in diameter and 
level. The mouth and throat were normal. There were no 
teeth. There was no rosary. The heart and lungs were nor- 
mal. The level of the abdomen was somewhat above that 
of the thorax; it was everywhere tympanitic and nothing 
abnormal could be detected. Very careful examination failed 
to find any enlargement of the kidneys. The liver was pal- 
pable 2 cm. below the costal border in the nipple line; the 
spleen was not palpable. The extremities were normal. 
There was no spasm, paralysis or tenderness. Neither active 
nor passive motions caused pain. The knee-jerks were equal 
and normal; Kernig's sign was absent. There was a slight 
general enlargement of the peripheral lymph nodes. She 
weighed thirteen pounds. 

The urine was pale with a slightly reddish tinge, feebly 
acid, of a specific gravity of 1,006 and contained a trace of 
albumin. The sediment showed a few red blood corpuscles 
and an occasional leucocyte, but no other formed elements. 

Diagnosis. The only causes of hematuria, not associated 
with bleeding elsewhere, in infancy, which really deserve 
consideration are irritation from crystals of uric acid, sarcoma 
of the kidney and scurvy. Tuberculosis of the kidney is 
almost unheard of at this age, and, when present, the urine 



DISEASES OF NUTRITION. II3 

more often contains pus than blood. Vesical calculi are also 
very unusual at this age and rarely cause hematuria at any 
age unless the patient is very active. Irritation from uric 
acid crystals can be ruled out in this instance on the examina- 
tion of the urine. The absence of frequent and painful 
micturition also make it improbable. The hematuria is 
perfectly consistent with either sarcoma of the kidney or 
scurvy. Pain is rare in sarcoma at this age, and constitutional 
symptoms are usually absent until the tumor has attained 
considerable size. Hematuria appears before the tumor is 
palpable in about forty per cent of the cases. Hematuria 
is not infrequently the earliest symptom of scurvy, appearing 
before pain and tenderness in the extremities or sponginess of 
the gums. An absolute diagnosis between sarcoma and scurvy 
in this instance is, therefore, impossible. The chances are 
very much in favor of scurvy, however, because of the much 
greater frequency of scurvy than of sarcoma of the kidney, 
the long continuance of the pasteurization of the milk, which 
predisposes to the development of scurvy, and the loss of 
appetite and failure to gain in weight, which usually precede 
and are almost invariably associated with scurvy. The 
chances are, in fact, so much in favor of Scurvy that it is 
justifiable to make a positive diagnosis of this disease and to 
consider sarcoma as merely an extremely remote possibility. 

Prognosis. The prognosis is perfectly good. The bleeding 
will almost certainly cease within a week under proper 
treatment. 

Treatment. The treatment is simple. It consists in stop- 
ping the pasteurization of the milk and in giving an ounce of 
orange juice daily. If it is inadvisable in any instance to omit 
pasteurization because of an unreliable supply of milk or hot 
weather, orange juice alone will cure the trouble. 



114 CASE HISTORIES IN PEDIATRICS. 

CASE 35. Margaret M. was the ninth child of healthy 
parents. All the others, except one that had died at birth, 
were alive. There was no history of tuberculosis in the family 
and no known exposure to tuberculosis. 

She was born at full term and was breast-fed for three 
weeks, since when she had been fed on condensed milk. 
The movements had always been green and loose. She had, 
however, taken her food well, had not vomited and had 
gained fairly well in weight. She began to vomit about the 
middle of July and a week later began to have from five to 
seven movements daily. These were watery, green or yellow 
in color, had a foul odor and contained a few small curds and 
considerable mucus. Blood was noticed once. She was ad- 
mitted to the Children's Hospital August 7, when three 
months old. Her temperature was then 104 F., but, as the 
result of treatment, dropped to normal the next day, where 
it remained, except for a rise of temperature lasting two 
days a few days later. 

Physical Examination at entrance. She was poorly de- 
veloped and much emaciated. There was moderate pallor. 
The mouth and tongue were red and dry. The anterior fon- 
tanelle was 3J cm. in diameter and depressed. The bones of 
the skull overlapped a little. There was no rosary. The 
heart and lungs showed nothing abnormal. The abdomen 
was sunken, but otherwise negative. The liver was palpable 
3 cm. below the costal border in the nipple line. The spleen 
was not palpafole. The extremities showed nothing abnormal. 
The knee-jerks were not obtained. The cervical lymph nodes 
were slightly enlarged. A few dysentery bacilli were found 
in the stools. 

Under careful treatment and feeding the vomiting and 
number of movements diminished and their character steadily 
improved, so that on August 17 she was having two pasty, 
yellow movements daily. She took her food well and did not 
vomit. At that time she was taking twelve feedings of two 
ounces of a mixture containing 2% of fat, 5% of sugar, 0.25% 
of whey proteids and 0.25% of casein. Her weight, however, 
had fallen from five pounds and fourteen ounces to five 
pounds and eight ounces. Her general condition was, if 



DISEASES OF NUTRITION. 115 

anything, worse than a few days before. The amount of food 
was increased to two and one-half ounces on the 18th, while 
the fats were increased to 2.50% and the sugar to 6% on the 
19th. She took her food well and did not vomit, but con- 
tinued to have from two to four perfectly normal movements 
daily. In spite of this, however, she continued to lose about 
one ounce daily, so that on the 21st she weighed but five 
pounds and four ounces. 

Diagnosis. The physical examination shows nothing ab- 
normal except the signs of malnutrition. It gives no clew as 
to its cause. The striking thing in the history is the pro- 
gressive loss of weight without any symptoms of indigestion 
or fever. The trouble is undoubtedly a recent one and the 
result of the mild attack of infectious diarrhea, since the baby 
had previously done fairly well. The only two conditions 
which need to be considered are starvation and infantile 
atrophy. The food taken August 17 gave 115 calories and 
1.4 grams of proteid per kilo, and that taken August 19, 160 
calories and 1.6 grams of proteid per kilo, more than enough 
to cover both the caloric and proteid needs. Starvation can, 
therefore, be ruled out. The picture corresponds exactly 
to the definition of Infantile Atrophy, a condition in which 
there is a progressive loss of weight in spite of a sufficient 
intake of food, there being at the same time no symptoms of 
disturbance of the digestion. 

Prognosis. The prognosis is practically hopeless unless 
the baby can get human milk. The chances are not very good 
if she can, because there is a strong probability that the dis- 
turbance of metabolism has gone so far that she will not be 
able to utilize even human milk. 

Treatment. The only treatment which offers any reason- 
able chance of recovery is human milk. She must have it 
at any cost. There is no other food which is worthy of con- 
sideration in this instance. There is nothing to be hoped 
from medicinal treatment. 



SECTION IV. 

SPECIFIC INFECTIOUS DISEASES. 

CASE 36. Bessie F. was born November 21, 1894. She 
was seen in consultation May 10, 1900. Both her parents 
had died of pulmonary tuberculosis during the previous year. 
She had lived with them up to the time of their death. One 
brother, six years old, was well. There had been no other 
children. 

She had measles when two years old and was said to have 
had influenza in February, 1900. She began to complain of 
pain in the abdomen about the first of March, 1900. The 
pain continued for several weeks and then ceased. Swelling 
of the abdomen was noticed about the middle of March and 
had slowly but steadily increased. Her appetite was good. 
She vomited after breakfast, however, two or three times a 
week. Her diet was a reasonable one for her age. Her bowels 
moved once in two or three days. The character of the move- 
ments had not been noted. She had had a cough during the 
day for about a month. She had lost both flesh and color. 

Physical Examination. She w^as well-developed and fairly 
nourished, but somewhat pale. She was bright and happy. 
Her tongue was moist and moderately coated. The heart 
was normal. There was slight dullness in both backs below 
the eighth space, with normal but somewhat diminished 
respiration and voice sounds. Fine, crackling, moist rales 
were occasionally heard in the dull area. The upper border of 
the liver flatness in the nipple line was in the fourth space. 
The lower border of flatness was 3 cm. above the costal border. 
The splenic dullness could not be determined. The edge of 
the spleen was not felt. The abdomen was much enlarged 
and the walls were tense. The distention was uniform. There 
was no enlargement of the superficial abdominal veins. 
There was dullness in the lower portion and in both flanks. 

117 



Il8 CASE HISTORIES IN PEDIATRICS. 

While the child lay on her back the upper line of dullness was 
concave. The rest of the abdomen was tympanitic. The 
area of dullness changed with change of position. A fluid 
wave was present. There was no edema of the extremities or 
of the face. There was no enlargement of the superficial 
lymph nodes. The rectal temperature was 99 F. ; the pulse, 
120. The urine showed nothing abnormal; the blood was 
not examined. 

Diagnosis. The principal abnormality observed in the 
physical examination is the presence of fluid in the abdominal 
cavity. Both borders of the liver are higher than they should 
be, while the total width of the liver flatness is normal, show- 
ing that the liver is merely displaced upward by the pressure 
of the fluid in the abdomen. The absence of the splenic 
dullness is presumably due to its displacement upward and 
backward. The rales show that the dullness and diminished 
respiration and voice sounds in the lower backs are not due 
to fluid in the pleural cavities. They are satisfactorily ex- 
plained by the displacement of the liver upward and the 
consequent compression and congestion of the lower portions 
of the lungs. This condition also explains the cough. 

The dullness in the flanks, the concavity of the upper border 
of the dullness, when she lies on her back, and the change of 
the area of dullness with change of position prove that the 
fluid is free in the abdomen and not confined in an ovarian 
or other cyst. 

Free fluid in the abdominal cavity may be due to causes 
either within or without the cavity. When due to causes 
outside of the abdominal cavity, there is usually edema of 
other parts of the body and, if the trouble is in the heart, the 
signs of passive congestion in other organs. The absence of 
edema and of the signs of passive congestion and the normal 
condition of the heart and urine rule out all causes outside of 
the abdomen in this instance. 

The possible causes located within the abdomen are those 
diseases and conditions which result in portal congestion and 
diseases of the peritoneum. The two causes of portal con- 
gestion are disease of the Hver and compression of the portal 
vein. The absence of enlargement of the spleen and of the 



SPECIFIC INFECTIOUS DISEASES. 119 

superficial abdominal veins makes portal congestion very 
improbable. The normal size of the liver practically excludes 
disease of this organ. The age of the child is also much against 
any chronic disease of the liver. The absence of an alcoholic 
or syphilitic history and of all signs of syphilis, the two most 
common causes of chronic disease of the liver at this age, 
makes disease of the liver still more improbable. Compression 
of the portal vein is usually due to a new growth of some sort, 
usually enlarged lymph nodes, they, in turn, usually being 
tubercular. In the light of the prolonged exposure to tuber- 
culosis, a tubercular infection of the abdominal lymph nodes 
is not at all unreasonable in this instance and cannot be 
excluded on the negative physical examination, because an 
enlarged lymph node, too small to be palpable, can, if located 
in the right place, exert much pressure on the portal vein. 
As already explained, however, the absence of enlargement of 
the spleen and of the superficial abdominal veins makes 
portal congestion very improbable. 

The diseases of the peritoneum to be considered are chronic 
serous peritonitis, malignant disease of the peritoneum and 
tubercular peritonitis. There is much doubt as to whether 
there is such a disease as chronic serous peritonitis. If there 
is, it almost never occurs before puberty. Malignant disease 
of the peritoneum is extremely rare, almost always results in 
palpable tumors and is accompanied by greater cachexia than 
is present in this instance. Both of these conditions can be 
excluded, therefore, if any other more reasonable explanation 
can be found. Tubercular peritonitis of the ascitic form is 
not at all uncommon at this age; the onset and progress of 
the illness in this instance are most characteristic of this 
disease; the prolonged exposure to tuberculosis makes a 
tubercular infection very probable. The diagnosis of Tuber- 
cular Peritonitis seems, therefore, amply justified. 

An examination of the ascitic fluid will aid' materially in 
confirming the diagnosis. The fluid from portal congestion 
is a transudation; that from disease of the peritoneum, an 
exudation. In the former the specific gravity of the fluid is 
below 1,015 an d it usually contains less than 2% of albumin, 
while in the latter, the specific gravity is above 1,015 and it 



120 CASE HISTORIES IN PEDIATRICS. 

usually contains more than 4% of albumin. The cells in a 
transudation are usually few and endothelial in character. 
The fluid in tubercular peritonitis usually contains many 
cells, and these are largely lymphocytes. Characteristic 
tumor cells are not infrequently found in the fluid when there 
is malignant disease of the peritoneum. Tubercle bacilli 
may often be found in the fluid in tubercular peritonitis, and 
animal inoculations are almost always positive. The diagno- 
sis of tubercular peritonitis is, however, justified in this 
instance without an examination of the fluid. 

A skin tuberculin test would be of interest in this child, but 
not of great aid in diagnosis. If positive, it merely shows that 
the child has a tubercular focus somewhere, not that the 
trouble in the abdomen is tubercular, although it is, of course, 
important corroborative evidence. If negative, it does not 
prove that the trouble in the abdomen is not tubercular, 
because the test is often negative when the tuberculosis is 
of the miliary type, as it is in this instance. 

Prognosis. Favorable points in this instance are the 
unusually good general condition, the absence of fever and 
of evidences of tuberculosis elsewhere. Her chances of re- 
covery are probably about even, provided she can have proper 
treatment. 

Treatment. The author does not believe in a routine 
operative treatment in this disease, even in the ascitic form, 
and does not think that, on the whole, the cases that are 
operated on do any better than those that are not. He 
believes in leaving the fluid alone unless it is causing too 
much discomfort or doing harm by the compression of other 
organs. He then believes in tapping rather than in opening 
the abdomen, leaving the latter as the last resort when the 
abdomen fills up rapidly after tapping. The treatment as 
regards the ascites is, therefore, in this instance, expectant. 
The further treatment is that of tuberculosis in general: 
an out-of-door life, day and night; quiet and forced feeding. 
There is no indication for drugs. 



SPECIFIC INFECTIOUS DISEASES. 121 

CASE 37. Mary D., seven years old, was the child of 
healthy parents. Three other children were well and one had 
died at birth. There was no tuberculosis in the family and no 
known exposure to tuberculosis. 

She was born at full term after a normal labor. She was 
nursed for eight months and did very well. During her fourth 
year she had had diphtheria, measles, whooping-cough and 
chicken pox, and was not in very good health during the next 
year. Since then she had been very well indeed. 

She was taken suddenly sick July 30 with a pain in the 
abdomen, but did not go to bed. The next day she vomited 
everything she took except water, and the pain continued. 
The pain and vomiting were worse on August 1 and she 
stayed in bed most of that day. She vomited the morning of 
August 2, but had no pain. She had no pain and did not vomit 
on the 3d and 4th, but stayed in bed. The bowels had moved 
regularly; the character of the movements was not known. 
She entered the Children's Hospital August 5. 

Physical Examination. She was well developed and nour- 
ished. She lay comfortably in bed and did not look acutely 
sick. The pupils were equal and reacted to light and accom- 
modation. There was no rigidity of the neck. There was 
moderate pallor of the skin and mucous membranes. The 
tongue was moist and covered with a thin white coat. The 
throat was normal. The heart and lungs showed nothing 
abnormal. The liver flatness extended from the upper border 
of the sixth rib to the costal margin; the edge was not felt. 
The upper border of splenic dullness was in the eighth space ; 
the edge was not felt. The abdomen was full and the walls 
were held rigidly. Examination was difficult, deep palpation 
being impossible. There were no rose spots. An indefinite 
mass was felt above the symphysis pubis, extending one half 
way to the umbilicus. This mass was still present after the 
bladder had been emptied by catheterization. There was 
also an indefinite resistance just above the right iliac crest. 
There was dullness in this region and over the mass in the 
hypogastrium. There was no shifting dullness and no fluid 
wave. There was slight general tenderness throughout the 
abdomen. The extremities showed nothing abnormal. There 



122 CASE HISTORIES IN PEDIATRICS. 

was no spasm or paralysis. The knee-jerks were not obtained. 
The plantar reflexes were normal. There was no edema. 
There was slight enlargement of the cervical lymph nodes. 
Rectal examination showed nothing abnormal. The tem- 
perature was 102° F. ; the pulse, 94; the respiration, 25. 

Urine (drawn by catheter): Normal color, acid, 1,018, no 
albumin or sugar. The sediment contained a few leucocytes 
and a few fine granular and hyaline casts. 

Blood: Leucocytes, 13,700. 

Diagnosis. The points which are of value in the differential 
diagnosis in this instance are an acute abdominal affection 
of five days' duration; the good general condition; a definite 
tumor in the hypogastrium when the bladder is empty; an 
indefinite resistance and dullness above the right iliac crest; 
the negative rectal examination; and the slight degree of 
the leucocytosis. 

The only diseases which are really worthy of consideration 
are appendicitis, some disease of the female pelvic organs 
and tubercular peritonitis. The urine shows merely a mild 
degenerative nephritis, which is of no importance either in 
diagnosis or in prognosis. The fever is consistent with all of 
these diseases and is, therefore, of no aid in the differential 
diagnosis. 

The history is much more suggestive of appendicitis than 
of the other conditions. Against it are the good general 
condition in spite of the tumor in the abdomen, the location 
of the tumor, the presence of another indefinite mass, the 
negative rectal examination and the slight degree of the 
leucocytosis. 

The location of the tumor is consistent with some inflam- 
matory process in the female pelvic organs. Against this 
diagnosis are the extreme rarity of inflammatory processes 
in these organs at this age, the location of the other indefinite 
mass, the negative rectal examination (which at this age 
amounts to a vaginal examination), and the slight degree of 
the leucocytosis. 

In favor of tubercular peritonitis is the presence of two 
masses, presumably due to the same cause, which do not 
correspond to the findings in any other condition and which 



SPECIFIC INFECTIOUS DISEASES. 123 

are consistent with the lesions found in tubercular peritonitis. 
The fact that these masses cannot be felt on rectal examina- 
tion is not inconsistent with the location of the tumors in 
tubercular peritonitis, but is with that of the tumors of ap- 
pendicitis and inflammatory processes in the pelvic organs. 
The slight degree of the leucocytosis is also consistent with 
tubercular peritonitis. The absence of a family history of or 
exposure to tuberculosis and the acuteness of the onset may 
be urged against the diagnosis of tubercular peritonitis. A 
tubercular family history is, however, of little or no impor- 
tance either for or against tuberculosis unless there has been 
exposure. The absence of a history of exposure to tuberculo- 
sis does not count in any way against tuberculosis, although, 
of course, a history of exposure points strongly toward it. 
The history of measles and whooping-cough in the past, 
both of which are known to predispose to the development of 
tuberculosis, is of some importance in this instance. An 
onset as acute as in this instance is unusual, but not un- 
common enough to count much against the diagnosis of 
tubercular peritonitis. The good general condition is more 
consistent with this disease than with the others under con- 
sideration. The diagnosis of Tubercular Peritonitis is, 
therefore, justified. It is undoubtedly of the caseous or 
librocaseous type. 

Prognosis. The prognosis in this type of tubercular 
peritonitis is not nearly as good as in the ascitic form. She 
probably has about one chance in three of recovery. 

Treatment. Operation cannot possibly do any good in this 
instance. The masses are too extensive to be removed, and 
opening the abdomen cannot of itself be of any benefit. The 
further treatment is that of tuberculosis in general; an out- 
of-door life day and night, quiet and forced feeding. There 
is no indication for drugs. 



124 CASE HISTORIES IN PEDIATRICS. 

CASE 38. George G., three years old, was the child of 
healthy parents. One other child was well and one had died 
of cerebrospinal meningitis " caused by a fall." There had 
been no miscarriages. There was no tuberculosis in the family 
and no known exposure to tuberculosis. He had always been 
perfectly well. 

It was noticed on September 4 that his appetite was poor 
and that he seemed dull, sleepy and tired. He continued in 
this condition, although up and about the house, until Sep- 
tember 10, when he went to bed. He vomited in the night 
and the next day seemed decidedly worse and began to com- 
plain of pain in the abdomen. That night he became restless, 
threw his head back on the pillow and " kicked out with his 
feet." He also became very cross and irritable. The irri- 
tability continued, but he remained conscious. He vomited 
again on September 12. The bowels were constipated from 
the beginning, moving only with enemata. The pain in the 
abdomen continued. He made no complaint of headache. 
Strabismus appeared on September 14 and persisted. That 
night he began to cry out as if in pain. This symptom con- 
tinued. He was admitted to the Children's Hospital 
September 16. 

Physical Examination. He was fairly well developed and 
nourished, but looked sick. He was dull mentally but con- 
scious. He could not speak plainly, but was able to make his 
wants known. He was irritable and cried out occasionally 
as if in pain. There was double convergent strabismus. 
He was able to see. The pupils were dilated and equal, but 
did not react to light. There was no discharge from the nose 
or ears. The lips were red and cracked. The tongue was 
dry and covered with a moderate brown coat. The tonsils 
were slightly reddened and prominent. There was no herpes. 
The heart and lungs showed nothing abnormal. The level of 
the abdomen was below that of the thorax; there was no 
definite muscular spasm; it was tympanitic and not tender; 
no masses were made out. The upper border of the liver 
flatness was at the upper border of the fifth rib ; the edge was 
palpable 3 cm. below the costal border in the nipple line. 
The spleen was not palpable. There were no rose spots or 



SPECIFIC INFECTIOUS DISEASES. 1 25 

petechiae. The head was not held backward, but there was 
slight rigidity of the neck and complete flexion was resisted 
and caused pain. There was no spasm or paralysis of the 
extremities. The knee-jerks were normal and equal. Ker- 
nig's and Babinski's signs were absent. There was no ankle 
clonus. Sensation to pain was normal. There was no en- 
largement of the peripheral lymph nodes. The rectal tem- 
perature was 102 F., the pulse no (normal is ioo), the 
respiration 30. The urine was high-colored, strongly acid, 
of a specific gravity of 1,026, and contained neither albumin 
nor sugar. The blood showed 23,000 leucocytes. 

Diagnosis. The early history suggests nothing more than 
a disturbance of digestion. The completed history points 
strongly to meningitis, although typhoid with symptoms of 
meningeal irritation is a possibility. The strabismus, the 
dilated and reactionless pupils, the slight rigidity of the neck 
and the pain on motion, the absence of enlargement of the 
spleen and of rose spots and the leucocytosis are sufficient, 
when taken together, to positively rule out typhoid. The 
absence of retraction of the head and of marked rigidity of 
the neck, of spasm or paralysis of the extremities and of 
Kernig's and Babinski's signs, as well as of changes in the 
knee-jerks, is somewhat unusual, but not enough so to count 
materially against meningitis. The relatively low pulse is 
consistent with either condition. The diagnosis of menin- 
gitis is, therefore, certain. 

The diagnosis of meningitis, however, is not sufficient. It 
is necessary to go further and to determine the kind of menin- 
gitis. When meningitis does not develop in the course of 
some other acute disease it is practically invariably either 
tubercular or cerebrospinal, and other types do not need 
to be considered. The diagnosis in this instance, therefore, 
lies between the tubercular and cerebrospinal forms. The 
diagnosis between tubercular and cerebrospinal meningitis 
in infancy and early childhood is often a very difficult one, 
because most of the points which help in the diagnosis in later 
childhood are so uncertain at this age that little dependence 
can be placed upon them. In most cases, however, a very 
probable diagnosis can be made. 



126 CASE HISTORIES IN PEDIATRICS. 

In this instance the absence of a tubercular family history 
and of exposure to tuberculosis does not count at all against 
tubercular meningitis or in favor of cerebrospinal meningitis. 
The slow onset is in favor of the tubercular form, but does not, 
by any means, rule out the cerebrospinal. The absence of 
herpes and eruptions does not count against the cerebrospinal 
form or in favor of the tubercular, because herpes and 
eruptions are very unusual in cerebrospinal meningitis at 
this age. Retraction of the head, marked rigidity of the 
neck, spasm and paralysis of the extremities, Kernig's and 
Babinski's signs, and changes in the pupils may be absent 
in both, but are more often wanting in the tubercular 
form. The leucocytosis is in favor of cerebrospinal menin- 
gitis, but is not inconsistent with the tubercular form, in 
which a leucocytosis sometimes occurs. The weight of the 
evidence is, therefore, somewhat in favor of Tubercular 
Meningitis, enough so, in fact, to justify this diagnosis. 
There is, however, a reasonable possibility that the trouble 
really is cerebrospinal meningitis. The only way in which an 
absolute diagnosis can be made is by lumbar puncture. 
Since lumbar puncture is a harmless procedure, and since 
cerebrospinal meningitis can in most instances be cured by 
the antimeningitis serum, a lumbar puncture should be done 
at once in order that he may have the advantage of the serum 
treatment if the disease is cerebrospinal meningitis instead 
of tubercular meningitis, as it seems. 

The normal cerebrospinal fluid is perfectly clear, like 
distilled water, does not form a fibrin clot on standing, and 
never contains more than 0.1% of albumin, or more than 
twenty cells per cubic millimeter. The vast majority of these 
cells are mononuclear. The fluid in tubercular meningitis is 
usually slightly turbid, sometimes clear, rarely very turbid 
or purulent, forms a fibrin clot on standing and contains more 
than 0.1% of albumin and more than twenty cells per cubic 
millimeter. The vast majority of these cells are mononuclear, 
usually lymphocytes, the percentage varying from 80 to 98. 
The proportion of polynuclear cells usually increases with the 
progress of the disease. Tubercle bacilli can be found in the 
fluid in about ninety per cent of the cases, if the examination 



SPECIFIC INFECTIOUS DISEASES. 127 

is careful enough. If the examination is hasty, they will 
usually be missed. A fluid should never be passed as normal 
because it appears clear when drawn. If a fibrin clot does not 
form in twenty-four hours, tubercular meningitis can be 
excluded. The fluid in cerebrospinal meningitis is usually 
markedly turbid, often purulent, sometimes nearly clear, 
forms a fibrin clot or a sediment of pus on standing, contains 
more than 0.1% of albumin and several hundred cells per 
cubic millimeter. The vast majority of these cells are poly- 
nuclear, the percentage usually varying between 75 and 90. 
The percentage of mononuclear cells gradually increases and 
finally exceeds the polynuclear in cases which recover. The 
meningococcus is almost invariably present in the acute 
stage. Under normal conditions the cerebrospinal fluid 
flows out slowly, drop by drop, while in both forms of menin- 
gitis it usually, but not always, flows out more rapidly or 
even spurts out. 

The fluid obtained by lumbar puncture in this instance 
was slightly cloudy, showed a definite fibrin clot in six hours, 
and contained one hundred and twenty-five cells to the 
cubic millimeter, 83% of which were lymphocytes. No 
organisms were seen in the examination of one cover slip. 
The diagnosis of tubercular meningitis is, therefore, verified 
by the results of the lumbar puncture. 

Prognosis. It is true that there are a few instances on 
record of recovery from tubercular meningitis. These are, 
however, so few in comparison with the vast number of fatal 
cases that it is not justifiable to give anything but an abso- 
lutely hopeless prognosis. 

Treatment. There is no curative treatment for tubercular 
meningitis. Repeated lumbar punctures will, however, often 
relieve headache and other symptoms of increased cerebral 
pressure, such as convulsions and twitching. It has no 
effect on the progress of the disease, and is not indicated at 
present in this instance. In spite of the hopeless prognosis, 
he must be nursed and fed as if he were certain to get well. 
If he will not swallow, he must be fed with a tube. Further 
treatment must be symptomatic. 



128 CASE HISTORIES IN PEDIATRICS. 

CASE 39. Girdham D., three years old, took rather a 
long walk with his mother the afternoon of December 27, 
which was a very cold and windy day. He had sausages for 
supper, which was not an unusual occurrence, and went to 
bed apparently perfectly well. He vomited several times 
during the latter part of the night. A physician who saw him 
the next morning found nothing abnormal on physical 
examination. He cleaned him out with castor oil, gave him 
bicarbonate of soda and limited his diet to broth and albumin 
water. He did not vomit any more, had a comfortable day 
and slept well the night of the 28th. He was a little stupid all 
day on the 29th, but from time to time complained of head- 
ache. In the afternoon the physician found that his neck was 
a little stiff and that his pulse was irregular. The bowels had 
not moved during the day. He was seen in consultation at 
6 P.M. 

Physical Examination. He was well developed and- nour- 
ished and of good color. He was somewhat stuporous but, 
when roused, was rational, although irritable. Passive 
movements of the neck were a little limited and caused some 
pain. The neck sign was absent. The membranae tym- 
panorum showed nothing abnormal. The pupils were equal 
and reacted to light. There was no enlargement of the cervical 
lymph nodes. The tongue was moderately coated, the throat 
normal. The heart was normal, except that it was somewhat 
irregular in force and rhythm. The lungs and abdomen 
showed nothing abnormal. The liver and spleen were not 
palpable. The extremities were normal. There was no spasm 
or paralysis; the knee-jerks were equal and normal; Kernig's 
and Babinski's signs were absent; there was no contra- 
lateral reflex. The rectal temperature was 101 F., the pulse 
140^ 

Diagnosis. The only conditions to be considered in this 
instance are intestinal toxemia and meningitis. The appear- 
ance of the symptoms of disturbed digestion immediately 
after the taking of improper food, following over-exertion and 
exposure to cold, make toxemia the more probable. The only 
things which really suggest meningitis are the persistence of 
the symptoms after catharsis and limitation of the diet and 



SPECIFIC INFECTIOUS DISEASES. 1 29 

the slight rigidity of the neck. Disturbances of digestion and 
toxemia not infrequently persist, however, after catharsis 
and starvation, and symptoms of meningeal irritation are 
not at all uncommon in intestinal toxemia. The slightly 
stuporous condition, the irritability and the irregularity of 
the pulse are consistent with either condition. The absence 
of all physical signs of meningeal irritation, except the slight 
rigidity of the neck, is strongly against meningitis, but does 
not exclude it, because these symptoms are not infrequently 
lacking for several days, or even longer, after the onset. The 
chances seem very much in favor of intestinal toxemia, but 
there is enough to suggest meningitis to justify a lumbar punc- 
ture for diagnosis. This is a harmless procedure and, now 
that cerebrospinal meningitis can usually be cured by the 
antimeningitis serum, if it is administered early, should be 
done in every case in which there is a reasonable probability 
of meningitis. The sudden onset and rather rapid develop- 
ment of the stuporous condition suggest cerebrospinal 
rather than tubercular meningitis, but they are not in- 
consistent with the tubercular form at this age. 

The fluid obtained by lumbar puncture was under high 
pressure and very turbid. A large fibrin clot formed en 
standing. The fluid contained 2,600 cells per cubic 
millimeter. So many of the cells were broken down that a 
differential count w T as impossible. There was, however, un- 
doubtedly a large excess of polynuclear cells. Numerous 
Gram-decolorizing diplococci were seen within the cells. 
(See Case 38 for description of the normal cerebrospinal 
fluid and of the fluid in meningitis.) The results of the exami- 
nation of the fluid obtained by lumbar puncture justify, of 
course, an absolute diagnosis of Cerebrospinal Meningitis. 

Prognosis. The chances for recovery, if he is treated with 
the antimeningitis serum, are better than even, because it 
is less than forty-eight hours since the onset, the symptoms 
are comparatively mild and the organisms are all within the 
cells. This latter point shows that nature is making a fairly 
successful struggle against the infection. 

Treatment. Another lumbar puncture must be performed 
as soon as the antimeningitis serum can be secured. All the 



130 CASE HISTORIES IN PEDIATRICS. 

fluid that will run out must be allowed to escape. An equal 
amount of serum must then be introduced through the same 
needle, provided that 30 ccm. or more has run out. If less 
than that has been obtained, 30 ccm. must still be given, un- 
less undue resistance is met in giving this amount. This, or 
a larger dose, according to the amount of fluid which escapes, 
must be repeated daily until no micro-organisms can be 
found in smears made from the fluid. If the temperature 
remains much elevated or the symptoms are not improving, 
the serum treatment must be continued even if the organisms 
have disappeared. Far better results are obtained from good- 
sized doses, frequently repeated, in the beginning, than from 
smaller doses or from the same or larger doses at longer inter- 
vals. Rigidity of the neck alone is not an indication for the 
continuance of the treatment, since rigidity often persists 
well into convalescence. No other treatment, except regula- 
tion of the bowels and of the diet, is indicated in this instance. 



SPECIFIC INFECTIOUS DISEASES. 131 

CASE 40. Timothy D., twelve years old, was the child of 
healthy parents. An uncle had died of pulmonary tubercu- 
losis a year before. He had not lived with him, but had seen 
him repeatedly. He had always been well, except for an 
illness " similar to the present " a year before. 

He began to be dizzy about August 26, but had no other 
symptoms except constipation. He was first seen by his 
physician September 2. The physical examination and the 
urine then showed nothing abnormal. His bowels were 
thoroughly cleaned out, but the dizziness persisted. Septem- 
ber 6 he began to complain of stiffness in the neck and held 
his head turned to the right. Passive motions were, however, 
but little limited and did not cause pain. The pupils were 
equal and reacted to light. The knee-jerks were equal and 
normal. Kernig's and Babinski's signs were absent. The 
neck was stiffer September 8 and he began to complain of 
pain in the neck. The pulse also became slow, running be- 
tween 56 and 64. He began to vomit on the 9th and the rigid- 
ity and pain in the neck became much worse. The highest 
temperature up to the morning of the 9th was 99 F. ; that 
morning it was ioo° F. The constipation had persisted. He 
was seen in consultation at 4 p.m., September 9. 

Physical Examination. He was well developed and nour- 
ished and of good color. He was perfectly conscious, but 
cried out occasionally from pain in the back of the neck. 
There was no retraction of the neck, but he held his head 
rigidly and turned to the right. All motions of the neck 
caused much pain. The neck sign could not be tested be- 
cause of the rigidity. There was no enlargement of the cervi- 
cal lymph nodes. The tongue was moderately coated; the 
throat normal. The pupils were equal and reacted both to 
light and accommodation. There was no strabismus. The 
membranae tympanorum showed nothing abnormal. The 
heart and lungs were normal. The liver and spleen were not 
palpable. The abdomen was sunken, but not rigid. There 
was no spasm or paralysis of the extremities. The knee-jerks 
were equal and not exaggerated. The cremasteric and ab- 
dominal reflexes were present and not unusually lively. 
There was a marked Kernig's sign on both sides. • Babinski's 



132 CASE HISTORIES IN PEDIATRICS. 

sign was absent and there was no clonus. There was no dis- 
turbance of sensation. There was no eruption. The taches 
cerebrates were marked. The mouth temperature was ioo° 
F., the pulse 60. 

Diagnosis. There can be no doubt, of course, that he has 
meningitis. The only question is whether it is tubercular or 
cerebrospinal. The known exposure to tuberculosis and the 
slow onset point strongly toward the tubercular form. There 
is nothing in the physical examination which is not consistent 
with either type. The absence of eruptions does not count 
at all against cerebrospinal meningitis since eruptions are 
far more often absent than present in this disease in child- 
hood. It may be remarked in passing that the taches cere- 
brales are of no importance in the diagnosis of meningitis, as 
they are present in all sorts of conditions in childhood. It is 
also worthy of mention that the abdomen, while often sunken 
from the lack of food, is almost never rigid in meningitis. In 
spite of the fact that the disease is almost certainly tubercular, 
a lumbar puncture should be done to make the diagnosis 
certain, because the fact that he has been exposed to tubercu- 
losis does not prove that he has contracted it, and because 
the onset of cerebrospinal meningitis is sometimes slow and, if 
it is cerebrospinal meningitis, the serum treatment may save 
him. 

A lumbar puncture was done at once and 45 ccm. of very 
turbid fluid under moderate pressure was allowed to run out. 
The marked turbidity of the fluid points very strongly to 
cerebrospinal meningitis (see Case 38 for description of the 
cerebrospinal fluid in health and disease), and much over- 
balances the points previously mentioned in favor of tubercu- 
lar meningitis. It justifies a probable diagnosis of Cere- 
brospinal Meningitis and makes it obligatory to treat him 
on this basis without waiting for the results of the examination 
of the fluid. 

Treatment. He should be given 45 ccm. of antimeningitis 
serum, which is equal to the amount of fluid withdrawn, 
through the same needle without withdrawing it. It is un- 
wise to wait for the examination of the fluid, because the 
symptoms are marked and the earlier the serum is given the 



SPECIFIC INFECTIOUS DISEASES. 133 

more likely he is to recover. The serum can do no harm if 
the disease proves to be tubercular and, if it is cerebro- 
spinal, considerable time is saved by not waiting for the ex- 
amination. If the examination of^ the cerebrospinal fluid 
shows that the trouble really is cerebrospinal meningitis, this, 
or a larger dose, according to the amount of fluid which escapes, 
must be repeated daily until no micro-organisms can be found 
in smears made from the fluid. If the temperature remains 
much elevated or the symptoms are not improving, the 
serum treatment must be continued even if the organisms 
have disappeared. Rigidity of the neck alone is, however, 
not an indication for the continuance of the treatment, since 
rigidity not infrequently persists well into convalescence. 
The withdrawal of the fluid will probably relieve the headache. 
If it does not, an ice cap will probably help it. 

The fluid which was withdrawn showed a small deposit of 
pus and a fibrin clot. Ninety-nine per cent of the cells were 
polynuclear and the diplococcus intracellulars was found 
both within and without the cells, thus verifying the diag- 
nosis of cerebrospinal meningitis. 

Prognosis. The prognosis in this instance is somewhat 
against recovery, because of the long duration of the illness 
before the beginning of treatment. The slow onset and the 
low temperature are, however, points in his favor. 



134 CASE HISTORIES IN PEDIATRICS. 

CASE 41. Simon R., seven years old, was taken suddenly 
sick on the night of March 6 with pain in his head and moder- 
ate fever. He vomited several times during the first twenty- 
four hours, but not afterward. His bowels were opened freely 
with calomel the next day and had moved daily since then. 
The movements were loose, but otherwise normal. He had 
had no cough or nose-bleed. The pain in the head continued 
and the temperature gradually rose to 105 F. He was seen 
in consultation March 10. 

Physical Examination. He was slight but muscular. His 
color was good. There was no eruption. He complained of 
pain all over his head, but of nothing else. He was perfectly 
rational. The pupils were equal and reacted to both light 
and accommodation. There was no strabismus or facial 
paralysis. The ear-drums were normal. The throat showed 
nothing abnormal. The tongue was dry and moderately 
coated. There was no tenderness or rigidity of the neck. 
The heart was normal. Percussion of the lungs showed noth- 
ing abnormal. The respiratory murmur and voice sounds were 
slightly diminished in the lower right back, but not changed 
in character. The level of the abdomen was below that of the 
thorax. The walls were lax and palpation was easy. There 
was no muscular spasm and no tenderness. The liver was not 
palpable. The upper border of the splenic dullness was on 
the eighth rib. The spleen was not palpable. There was 
no spasm or paralysis of the extremities. The knee-jerks 
were lively and equal. Kernig's and Babinski's signs were 
absent. Sensation to touch was normal. The cervical lymph 
nodes were slightly enlarged. The temperature by mouth 
was 105 F., the pulse no, the respiration 28. 

Diagnosis. Several diseases which it would have been 
necessary to consider at first, because of the acute onset, can 
now be ruled out on the duration of the illness and the 
absence of their typical symptoms and physical signs after 
four days. These are acute indigestion, malaria, scarlet fever, 
tonsillitis and otitis media. The other diseases which are 
suggested by the history are pneumonia, meningitis (more 
probably cerebrospinal than tubercular) and influenza. 

The acute onset with vomiting and the continued high 



SPECIFIC INFECTIOUS DISEASES. 1 35 

temperature are very characteristic of pneumonia; the head- 
ache is not inconsistent with this diagnosis. Cough, while 
often absent for one or two days, almost always develops, 
however, by the fourth day. The physical signs in the lungs, 
namely, localized diminution of the respiratory murmur and 
voice sounds, are rather characteristic of pneumonia in an 
early stage and are often all that can be found for several days. 
Something more definite would, however, be expected by the 
fourth day. The pulse is slower than would be expected with 
a temperature of 105 F. in pneumonia, and the rate of the 
respiration is not increased out of proportion to that of the 
pulse. This latter point is an extremely important one and, 
when taken in connection with the indefiniteness of the symp- 
toms and physical signs, is sufficient to rule out pneumonia. 

The acute onset, the persistence of the headache and the 
relatively slow pulse and respiration suggest meningitis. The 
clear mind and the absence of all signs of meningeal irritation 
make it, however, extremely improbable. It is certainly not 
probable enough to justify a lumbar puncture for diagnosis. 

The history and lack of physical signs are consistent with 
influenza. The duration of the illness without the develop- 
ment of any catarrhal symptoms, the relatively slight prostra- 
tion and the comparatively slow pulse are, however, against 
it. Influenza seems a more reasonable diagnosis than the 
others, but is far from being satisfactory. 

Is there any other disease which will explain the symptoms 
and physical signs better? There is, and that disease is 
typhoid fever. An acute onset is not unusual in typhoid 
in children. Nose-bleed is relatively infrequent at this 
age. A diffuse headache is characteristic of this disease. 
The spleen is enlarged (the normal upper limit of dullness is 
at the ninth rib) . The relatively slow pulse (the normal rate 
at seven years is 90), without any symptoms of increased 
cerebral pressure or meningeal irritation, is almost pathogno- 
monic. It is too early for rose spots, and abdominal symp- 
toms are as often absent as present in typhoid at this age. 
A probable diagnosis of Typhoid Fever seems, therefore, 
justified. 

There are several laboratory tests which may be tried 



I36 CASE HISTORIES IN PEDIATRICS. 

which will aid more or less in the diagnosis. Typhoid fever 
has no leucocy tosis ; neither has influenza. A white count 
will be, therefore, of no assistance in differentiating between 
these two diseases. A low white count will, in this instance, 
practically rule out pneumonia and cerebrospinal meningitis. 
Pneumonia, meningitis and typhoid all show the diazo- 
reaction; influenza does not. This test might, therefore, be 
of some assistance in differentiating between typhoid and 
influenza. It is too early to expect a positive Widal reaction, 
and it is hardly worth while to try it at present. A blood 
culture will almost certainly settle the diagnosis at once, as 
they are positive in about ninety per cent of all cases of 
typhoid at this stage. 

Prognosis. The prognosis of typhoid fever at this age is 
very good. He is in good condition and his prognosis is at 
least as good as the average. The duration of the fever will 
probably not be over three weeks. There is very little chance 
of hemorrhage, practically none of perforation. 

Treatment. He must, of course, be kept in bed. The 
author does not believe in a strict milk diet in this disease. 
It does not provide enough calories, is very monotonous and 
tends to cause constipation. He is very sure that patients 
who are fed more liberally are in better condition at the 
end of the disease and that they convalesce more rapidly. 
Broths and beef tea have almost no nutritive value, 
are likely to stir up peristalsis, and should consequently 
be given but sparingly. A suitable diet for this boy is as 
follows : 

Milk, broth, beef tea, barley jelly, rice jelly, farina, milk 
toast, blanc mange, baked custard, junket, ice cream. 

His fever will probably not require much treatment. If 
his temperature is constantly over 104 F., or he is depressed, 
or shows symptoms of disturbance of the nervous system as 
the result of the fever, it will require treatment. Sponge 
baths of alcohol and water, equal parts, at 90 F., every four 
hours, will probably be sufficient to control it. An ice-cap 
for the headache and suds enemata for constipation, if 
present, are all that are necessary at present in addition to 
regulation of the diet and baths. 



SPECIFIC INFECTIOUS DISEASES. 1 37 

CASE 42. Althea P., five and one-half months old, was 
the only child of healthy parents and had always been per- 
fectly well. There had been no miscarriages. Her father had 
had a severe " cold " in his throat and nose about two weeks 
before. She had had a " cold in the nose " for a week, but 
had not appeared sick or feverish. She had taken the breast 
well up to the last two days. The discharge had irritated 
the upper lip a little. There had been no other symptoms. 

Physical Examination. She was well developed and nour- 
ished and of good color. The anterior fontanelle was 3 cm. 
in diameter and level. She showed a slight tendency to keep 
her mouth open. There was a small amount of thin, watery 
discharge from the nose which irritated the upper lip. The 
turbinates were a little swollen and reddened and had a few 
crusts on them. No membrane was seen. The throat was 
perfectly normal. There was no rosary. The heart and lungs 
were normal. The level of the abdomen was that of the 
thorax. It showed nothing abnormal. The liver was palpable 
2 cm. below the costal border in the nipple line. The spleen 
was not palpable. The extremities were normal. There was 
no spasm or paralysis. The knee-jerks were equal and normal. 
Kernig's and Babinski's signs were absent. There was no 
enlargement of the peripheral lymph nodes The rectal 
temperature was 99. 2 F. 

Diagnosis. Syphilitic rhinitis can be at once excluded on 
the good family history, the previous good health, the good 
general condition, the history of exposure to her father's 
11 cold " and the absence of all other signs of syphilis. The 
only thing to suggest diphtheritic rhinitis is the persistence 
of a watery discharge which irritates the upper lip. The 
absence of constitutional symptoms, fever and enlargement of 
the cervical lymph nodes does not count at all against diph- 
theritic rhinitis, because a persistent, irritating, nasal dis- 
charge without other symptoms is most characteristic of this 
disease in infancy. The chances are, of course, much in 
favor of a simple rhinitis, but the watery, irritating character 
of the discharge is suspicious enough to demand a bacterio- 
logical examination. This was made and an almost pure 
culture of the Klebs-Loeffler bacillus was found, justifying 



I38 CASE HISTORIES IN PEDIATRICS. 

the suspicion of Diphtheritic Rhinitis. The presumption is 
that her father had had diphtheria and that she had caught 
it from him. 

Prognosis. The prognosis is perfectly good. Extension of 
the process is very unusual, even if it is untreated. The 
chief danger is of infection of those about her. 

Treatment. The treatment is the administration of the 
antitoxin of diphtheria. Fifteen hundred units, repeated in 
two days, will probably be sufficient; more must be given if 
the discharge persists. Local treatment is hardly necessary, 
but some simple alkaline solution, dropped in the nose with a 
medicine dropper, every few hours, will probably make her 
more comfortable. She must be isolated until two consecutive 
negative cultures have been obtained from both the nose and 
throat. 



SPECIFIC INFECTIOUS DISEASES. 1 39 

CASE 43. Martin S., six years old, began to have a loud, 
ringing cough with slight difficulty in breathing during the 
night of May 23. The cough and difficult respiration con- 
tinued without diminution during the 24th. That night the 
difficulty in respiration increased considerably, so that he 
slept but little. He was no better on the morning of the 25th 
and was not able to talk aloud. During the day the difficulty 
in breathing increased very rapidly, so that he had to sit up 
to breathe. He became cyanotic and was unable to take 
nourishment. His temperature during these days had ranged 
from normal to 101 F. Repeated examinations of the throat 
had shown nothing abnormal. He was seen in consultation 
at 7.30 p.m., May 25. 

Physical Examination. He was a large, strong boy. He 
was markedly cyanotic and was sitting up in bed with his 
head stretched forward. The inspiration was noisy. The 
cough was harsh and dry. He was unable to speak above a 
whisper. The cervical lymph nodes were slightly enlarged. 
The tonsils were moderately enlarged and somewhat reddened, 
but there was no exudation upon them. There was no nasal 
discharge. There was sinking in of the supraclavicular spaces, 
of the lower intercostal spaces and of the epigastrium with 
each inspiration. Percussion of the lungs was normal. The 
respiratory murmur was very feeble, but not abnormal in 
character. Very many loud, dry and coarse, moist rales were 
heard over both chests. The rales were alike in both chests 
and both behind and in front. There was nothing abnormal 
about the heart except the rapidity of its action. The 
abdomen was normal. The liver and spleen were not palpable. 
The extremities w^ere not examined. The axillary tempera- 
ture was 101 F., the pulse 150, the respiration 24. 

Diagnosis. The cyanosis and the retraction of the epi- 
gastrium, intercostal and supraclavicular spaces are simply 
manifestations of some obstruction to the entrance of air 
into the lungs and do not indicate where the obstruction is 
located. The head is stretched forward in order to make 
breathing easier by straightening the upper air passages. 
The normal condition of the nose and throat rules out ob- 
struction above the larynx. The signs in the lungs are not 



140 CASE HISTORIES IN PEDIATRICS. 

sufficient to account for so much cyanosis and retraction. 
The fact that the rales are alike in both chests, both back and 
front, shows, moreover, that they are not made in the bronchi, 
but transmitted from above. The relatively low rate of the 
respiration also shows that the trouble in the lungs is not the 
cause of the cyanosis and retraction. The obstruction must, 
therefore, be situated in the larynx. The noisy inspiration, 
the harsh dry cough and the whispering are all characteristic 
of inflammation of the larynx and corroborative of the 
diagnosis of laryngeal obstruction. 

The next point to be determined is whether the trouble in 
the larynx is catarrhal or diphtheritic. The progressive 
increase in the difficulty in respiration is almost pathognomonic 
of laryngeal diphtheria and entirely different from the course 
of catarrhal laryngitis, in which the obstruction is not con- 
tinuous and progressive, but occurs in paroxysms, being 
worse at night than during the day. The progressive in- 
crease in the symptoms is of itself sufficient to justify the 
diagnosis of Laryngeal Diphtheria. The slight degree of 
the fever is consistent with either condition, but is more 
characteristic of laryngeal diphtheria than of catarrhal 
laryngitis, in which the temperature is usually higher. The 
absence of marked inflammation of the throat and of enlarge- 
ment of the cervical lymph nodes does not count at all against 
laryngeal diphtheria because in primary laryngeal diphtheria 
the throat is usually not involved and, as there is but little 
absorption from the larynx, the lymph nodes are not enlarged. 
It would be criminal, in this instance, to await bacteriological 
verification of the diagnosis. A negative culture, if taken 
from the throat, would not, in fact, invalidate the diagnosis 
of laryngeal diphtheria, because the diphtheria bacilli are 
often absent from the throat when the diphtheritic process 
begins in the larynx. 

Prognosis. The prognosis is practically hopeless without 
intubation, and very grave with intubation unless antitoxin 
is given freely. With intubation and antitoxin the chances 
are in his favor, because he is in good general condition, there 
is no involvement of the throat, practically no septic absorp- 
tion and his heart is strong. 



SPECIFIC INFECTIOUS DISEASES. I4I 

Treatment. Intubation should be done at once. He 
should be given six thousand units of antitoxin as soon as he 
has quieted down after the intubation. This dose should be 
repeated in eight hours. It is impossible to state in advance 
whether he will need more or not. If his temperature drops 
to normal and the general condition remains good, it will 
probably not be necessary to repeat it. If he coughs up the 
tube and the obstruction does not return, further doses will 
not be needed; otherwise, the antitoxin must be continued, 
perhaps in larger doses. The tube should be removed on the 
third or fourth day. If the obstruction recurs it must be 
replaced. It is far wiser to have some one competent to 
remove and replace the tube in the house as long as the tube 
is in the larynx than to leave him alone, because emergencies, 
such as blocking of the tube and coughing up the tube, are 
liable to occur at any time and, if not met immediately, are 
likely to prove fatal. 

The food should be milk and soft solids, like junket, baked 
custard, ice cream, soft cereals and soft toast. Some children 
take liquids better; some, soft solids. It is impossible to tell 
in advance which he will take better. Most children take 
their food best sitting up. It is wiser, therefore, to try him 
first in this position. If he has trouble in taking it in this way 
he may be able to take it better lying on his back with his 
head lower than his body. If he has much difficulty in taking 
food, it is safer to feed him with a tube introduced through 
the mouth than to persist with other methods. No other 
treatment is indicated at present. 



I42 CASE HISTORIES IN PEDIATRICS. 

CASE 44. Isabelle C, eight years old, had had measles 
but not scarlet fever. She had been perfectly well during the 
last six months. She slept well the night of November 16, 
ate her usual breakfast, had a normal movement of the bowels 
and went to school apparently in good health. Soon after 
reaching school she began to have a rather severe headache, 
but said nothing about it. When her father went after her at 
noon, he found her very feverish and having a chill. She was 
a little nauseated, complained of headache and was very 
nervous and excited. She was seen at 3 p.m. 

Physical Examination. She was well developed and nour- 
ished and in good general condition. She was very nervous 
and much excited. She complained of feeling cold and of 
headache. The headache was general, not localized. She 
was generally hyperesthetic. There was no rigidity or tender- 
ness of the neck. The pupils were equal and reacted to light. 
The throat was normal. The tongue was slightly coated. 
The membranae tympanorum were normal. The heart and 
lungs were normal. The liver and spleen were not palpable. 
The level of the abdomen was that of the thorax; nothing 
abnormal could be detected in it. There was no spasm or 
paralysis. The knee-jerks were equal and normal; Kernig's 
and Babinski's as well as the neck sign were absent. There 
Avas no enlargement of the peripheral lymph nodes and no 
eruption. The temperature, by mouth, was 102. 8° F., the 
pulse 120, the respiration 35. 

The urine was high in color, acid in reaction, of a specific 
gravity of 1,024, an d contained no albumin or sugar. 

The leucocytes numbered 8,100. No plasmodia were seen. 

Diagnosis. This onset is consistent with that of almost 
any of the acute diseases. Certain of them are, however, 
much more probable than the others. These are scarlet 
fever, tonsillitis, influenza and pneumonia. 

Malaria is unlikely in November, and in Boston. It is 
excluded by the absence of plasmodia in the blood. The 
acute onset with headache suggests, to a certain extent, 
meningitis. The hyperesthesia is also rather suggestive. 
The headache and hyperesthesia are, however, equally well 
explained by the temperature. An onset as acute as this is 



SPECIFIC INFECTIOUS DISEASES. 143 

very unusual in tubercular meningitis at this age. The ab- 
sence of all signs of meningeal irritation is also against 
meningitis in any form. The low white count practically 
rules out cerebrospinal meningitis. The absence of sore throat 
at this time, only a few hours after the onset, does not, of 
course, rule out scarlet fever and tonsillitis, but makes them 
somewhat improbable. Neither a rash nor signs in the lungs 
can be expected thus early. The relatively greater increase 
in the rate of the respiration over that of the pulse suggests 
pneumonia, but it is hardly marked enough to be of much 
importance. There is nothing about the onset and symptoms 
inconsistent with influenza, and the absence of physical signs 
is entirely consistent with this disease. The leucocyte count 
is of great assistance in this instance. The low count practi- 
cally rules out scarlet fever, tonsillitis and pneumonia, all of 
which have a marked leucocytosis, and is characteristic of 
influenza, the only other condition to be seriously considered. 
The diagnosis of Influenza seems, therefore, justified. 

Prognosis. There is, naturally, no danger as to life. The 
fever will probably not last many days and she will be able 
to return to school in a week or ten days. 

Treatment. The treatment is simple; a tablespoonful of 
castor oil, laxol or syrup of senna, to empty the bowels; a 
diet of milk, broth and simple starchy foods; an ice-cap for 
the headache; phenacetin and salol, 2 \ grains each, every 
three hours, for the headache and general discomfort. 



144 CASE HISTORIES IN PEDIATRICS. 

CASE 45. Leonard O., nineteen months old, had always 
been well. He was in Windham, Conn., on a visit from Sep- 
tember 27 to October 4. He was well while there but was 
severely bitten by mosquitoes. Al though the weather was 
cool and he had eaten nothing unusual, he began to have 
loose movements of the bowels October 17. He continued to 
have four or five loose, greenish movements, without curds or 
mucus, daily. His appetite was poor, but he did not vomit. 
He was feverish and sick all day on the 17th, but, aside from 
the loose movements, had no very definite symptoms. He 
was fairly well on the 18th, but was worse again on the 19th. 
When he w T oke in the morning of the 21st he was cold and 
rather blue and his face looked pinched. Heaters were ap- 
plied and brandy given, and after a few hours he became 
warm again. He then seemed a good deal relaxed, sweat 
quite freely and was depressed all day. He was seen October 
22. He then appeared fairly well, but was quiet and looked 
run down. 

Physical Examination. He was well developed and nour- 
ished, but rather flabby. Pallor was marked. He had twelve 
teeth. The anterior fontanelle was not quite closed. The 
tongue was clean and the throat normal. There was a slight 
rosary. The heart, lungs and abdomen were normal. The 
liver was palpable 3 cm., and the spleen 1 cm., below the costal 
border. The extremities were normal. There was no spasm 
or paralysis. The knee-jerks were equal and normal. There 
was no enlargement of the peripheral lymph nodes. The 
rectal temperature was normal. A movement which was 
seen was watery, black (presumably from bismuth) and foul, 
but contained no curds or mucus. The urine was pale, 
slightly acid in reaction, of a specific gravity of 1,012 and 
contained no albumin. 

Diagnosis. The periodic increase in the severity of the 
symptoms ought at once to suggest the possibility of malaria, 
in spite of the persistance of the diarrhea. The peculiar 
condition on waking on the 21st, taken in connection with 
the subsequent sweating and depression, makes this diagnosis 
very probable. In fact, this combination is very character- 
istic of the malarial paroxysm in infancy, at which age the 



SPECIFIC INFECTIOUS DISEASES. 145 

chill is usually replaced by cyanosis and cold extremities. 
The sweating in this instance was, however, more pronounced 
than is usual. The marked pallor and the enlargement of 
the spleen are further corroborative evidence. A slight 
enlargement of the spleen, as in this instance, is, however, not 
very uncommon in many acute infections in infancy. The 
enlargement may, moreover, be a chronic one due to the same 
disturbance of nutrition in the past which caused the rickets, 
the results of which are shown in the open fontanelle, the 
slightly delayed dentition and the rosary. Further evidences 
in favor of malaria are the stay in a malarial district and the 
fact that he was bitten by mosquitoes. The time between the 
possible infection and the development of the symptoms 
corresponds, moreover, to the average incubation period of 
malaria. The diagnosis of Malaria is, therefore, justified. 
This diagnosis should, however, never be made positively 
without an examination of the blood. The blood was ex- 
amined in this instance and a single infection with the tertian 
organism found. 

Prognosis. The prognosis is, of course, good. Malaria in 
infancy usually yields very promptly to treatment. 

Treatment. The treatment is, of course, the administration 
of quinine. The same rules apply to its use in infancy as in 
later life. Babies will usually take the sulphate of quinine in 
solution by mouth without difficulty and without vomiting. 
If it is vomited it may be given in a suppository. It is rarely 
necessary to give it subcutaneously. This boy should have 
2 grains of the sulphate of quinine by mouth, or 2\ grains by 
rectum, in the late evening of the 22d, 24th, 26th and 28th. 
He ought not to have any paroxysms after the first two doses 
and, theoretically, should be cured by the four doses. In 
order to be doubly safe, however, it will be well to give him 
1 grain of sulphate of quinine twice daily for two days, four 
times, at intervals of a week. The saccharated carbonate of 
iron, in doses of 3 grains, three times daily, after eating, will 
help the anemia. The loose movements are a symptom of 
the malaria and will cease with the cure of this condition. 



I46 CASE HISTORIES IN PEDIATRICS. 

CASE 46. Ruth A., three and one-half years old, had 
always been well, except for an attack of chicken-pox a year 
previously. She became a little feverish and began to com- 
plain of pain in the left wrist during the afternoon of March 
9. Her temperature that night was 100. 5 F. Nothing ab- 
normal was detected about the arm. There was no history 
of any injury. The next morning the temperature was 
1 02. 5 F. and there was more pain and some tenderness, but 
no heat or redness, in the wrist. From this time on the 
temperature and the pulse-rate rose steadily and the pain 
became very severe. Aspirin, in fairly large doses, had had 
no effect on either the pain or the temperature. She had had 
no chills and had not vomited. She was seen in consultation 
late in the afternoon of March 11, forty-eight hours after 
the onset. 

Physical Examination. She was well" developed and nour- 
ished and of good color. She was actively delirious but, when 
roused, answered rationally. There was no rigidity or tender- 
ness of the neck and no neck sign. The pupils were equal and 
reacted to light. The throat was normal, the tongue moder- 
ately coated. The heart, lungs and abdomen were normal. 
The liver and spleen were not palpable. The extremities 
were normal, except for the left arm. There was no spasm or 
paralysis. The knee-jerks were equal and normal. Kernig's 
sign was absent. The lymph nodes in the left axilla were 
slightly enlarged and tender; the other peripheral lymph 
nodes were not palpable. There was considerable deep swell- 
ing in the- upper two thirds of the left forearm with moderate 
tenderness on pressure, more marked over the radius than over 
the ulna. There was no redness, but some heat. There was 
also a little swelling about the elbow- joint and in the lower 
portion of the upper arm. There was no tenderness over the 
elbow-joint and no evidences of effusion into the joint. 
Passive motions were slightly limited at the elbow, but not 
at the wrist. The rectal temperature was 104 F., the pulse 
160. 

Diagnosis. The diagnosis is not a difficult one. Scurvy 
can be ruled out by the age of the child, the acuteness of the 
onset, the high temperature and the localization of the process 



SPECIFIC INFECTIOUS DISEASES. 1 47 

in one extremity. Rheumatism is unusual at this age and, as 
a rule, its symptoms are mild. If they are severe, they are 
located in the joints, not in or about the shafts of the bones, 
and several joints are involved at once. Inflammation of 
the superficial tissues can be ruled out by the absence of 
redness and the deepness of the swelling. The trouble must, 
therefore, be located in or about the shafts of the bones, that 
is, it is an osteomyelitis or a periosteitis. It is unimportant 
for practical purposes whether it is a periosteitis, an osteo- 
myelitis or both, for in any case an immediate operation is 
necessary. The swelling shows that there is certainly a 
Periosteitis. In all probability there is an Osteomyelitis 
also, although the absence of extreme localized tenderness is 
somewhat against it. 

Prognosis. The prognosis is very grave. The chances are 
much against recovery even with an immediate operation. 

Treatment. The treatment is immediate operation. 



I48 CASE HISTORIES IN PEDIATRICS. 

CASE 47. John D. was the second child. The first child 
was born dead at eight months. There had been no other 
pregnancies. His mother had had no symptoms of syphilis; 
his father was not seen. 

He was born at full term after a normal labor and was 
normal at birth. Dryness of the palms and soles and cracking 
of the lips was noticed when he was two weeks old. A week 
later he began to have trouble in breathing through his nose 
and kept his mouth open. The trouble in breathing steadily 
increased, and when he was four and a half weeks old he 
began to have great difficulty in nursing. He did not vomit. 
The movements from the bowels were normal. He had had 
no fever. He w T as seen in consultation when five weeks old. 

Physical Examination. He was small but well-nourished. 
There was slight cyanosis of the lips and extremities. The 
anterior fontanelle was 3 cm. in diameter and slightly de- 
pressed. The posterior fontanelle was not quite closed. 
The pupils were equal and reacted to light/l There was no 
strabismus. There was a slight purulent discharge from the 
left eye. He lay with his head held back. The neck was, 
however, freely moveable. His mouth was open and no air 
entered through the nose. His breathing was irregular, 
difficult and rapid. There was a slight purulent discharge 
from one nostril. The nasal mucous membrane was much 
swollen, but no membrane was visible. A probe could be 
passed through both nostrils, but with considerable difficulty; 
its passage caused bleeding. Examination with forceps by a 
nose and throat specialist showed no adenoid growth. There 
was nothing abnormal in the pharynx or in the region of the 
tongue. The lips were cracked. There was retraction of the 
epigastrium with inspiration. The heart and lungs were 
normal, except that at times no respiratory sound could be 
heard. The cry was strong and of normal character, when he 
had breath enough to cry. The abdomen was negative. 
There was no enlargement of the liver or spleen. The genitals 
were normal. There were no mucous patches about the anus. 
The extremities were normal except for redness, thickening 
and scaling of the palms and soles. There was no spasm or 
paralysis of the face or of the extremities. The knee-jerks 



SPECIFIC INFECTIOUS DISEASES. 149 

were equal and normal. Kernig's sign was absent. There 
was a fine desquamation over the whole body, but no erup- 
tion or scars of any old eruption. The rectal temperature 
was 104 F. ; the pulse 160, but fairly strong. The baby 
seemed a good deal exhausted. 

Diagnosis. The purulent discharge from the eye is an 
incidental and unimportant complication. The retraction of 
the epigastrium with inspiration shows that there is an ob- 
struction to the entrance of air somewhere in the respiratory 
tract, but gives no hint as to the location of the obstruction. 
The cyanosis has the same significance. The clear, strong 
cry rules out any obstruction in the larynx. The high tem- 
perature and rapid respiration suggest some pathological 
condition in the lungs. The character of the respiration and 
the absence of physical signs in the lungs rule this out, how- 
ever, and the temperature can be explained equally well by 
toxic absorption from the nose and exhaustion. The negative 
examination of the throat rules out obstruction from adenoids, 
retropharyngeal abscess or malformation. The obstruction 
to the entrance of air must, therefore, be located in the nose. 
The reason that the baby is so much troubled by this obstruc- 
tion is that he has not yet learned to breathe through his 
mouth, and that it prevents him from getting sufficient 
nourishment. It is the nasal obstruction which is causing 
the serious symptoms in this instance, and it is this condition 
which must be relieved in order to save the baby's life. The 
retraction of the head is not a sign of meningitis, but merely 
the result of the baby's effort to get more air by straightening 
the upper air passages. 

The possible causes of the nasal obstruction in this instance 
are simple rhinitis, diphtheritic rhinitis and syphilitic rhinitis. 
Any one of them, even the simple rhinitis, can, at this age, 
cause symptoms as serious as those present in this instance. 
Both simple and diphtheritic rhinitis usually have more dis- 
charge than there is in this instance, and the discharge in 
nasal diphtheria is usually thin and irritating. The absence 
of visible membrane does not rule out nasal diphtheria, be- 
cause it is often absent or out of sight in this disease. While, 
however, there is nothing about the symptoms or local con- 



150 CASE HISTORIES IN PEDIATRICS. 

ditions to exclude simple or diphtheritic rhinitis, there is 
much in the history and physical examination which points 
toward syphilitic rhinitis. The previous stillbirth, the ap- 
pearance of dryness of the palms and soles and cracking of the 
lips at two weeks and of nasal obstruction at three weeks, and 
the redness, thickening and scaling of the palms and soles, 
while individually not of much importance, together make 
the diagnosis of Syphilitic Rhinitis practically certain. The 
good health of the mother does not, of course, count in any 
way against the diagnosis of syphilis, because syphilis is 
often transmitted from father to child, although the mother 
shows no signs of the disease. 

Prognosis. The prognosis is very grave, because the cause 
of the obstruction, the syphilis, cannot be removed at once 
and it is doubtful whether the nasal obstruction can be re- 
lieved by local treatment for so long a time as will be required 
to get the syphilis under control. A point in his favor is that 
he is nursed. 

Treatment. The specific treatment of the syphilis must, of 
course, be begun at once. The local treatment of the nasal 
obstruction is, however, of more immediate importance and, 
next to this, the administration of food. A 1-5,000 solution of 
adrenalin chloride is more likely to relieve the nasal obstruc- 
tion than anything else. This is best applied by dropping it 
into the nose with a medicine dropper while the baby is lying 
on its back, so that it can run downward over the nasal 
mucosa. Five drops in each nostril every hour should be 
sufficient. If it is not effective in this strength, it is hardly 
worth while to try stronger solutions. If it does not give 
relief, a 0.5% solution of cocaine may be tried. This must be 
used cautiously, as babies are very easily poisoned by cocaine. 
If these measures are unsuccessful, pieces of rubber tube (a 
catheter is suitable) , as large as can be passed into the nose 
and long enough to reach the pharynx, may be inserted into 
both nostrils. 

If the nasal obstruction is relieved by these procedures the 
baby will probably be able to take the breast. If he is no*, 
the milk must be withdrawn with a breast pump or squeezed 
out by hand and given to him with a dropper or a Breck 



SPECIFIC INFECTIOUS DISEASES. 151 

feeder, or through a stomach-tube passed through the mouth. 
He ought to get at least sixteen ounces in the twenty-four 
hours; twenty ounces if possible. 

A piece of mercury ointment, half the strength of the offici- 
nal unguentum hydrargyrum, the size of a large pea, should 
be rubbed in daily, the location of the application varying 
from day to day. This should be continued, with occasional 
short interruptions, for a year. It must be remembered in 
this connection that the earliest symptom of mercurial 
poisoning in infancy is diarrhea, not salivation. It should 
then be used, as a matter of precaution, one month in every 
three for three or four years and, even if there are no symp- 
toms, again for a couple of years at the time of the second 
dentition, and at puberty. 



SECTION V. 

DISEASES OF THE NOSE, THROAT, EARS AND 

LARYNX. 

CASE 48. Virginia G., seven months old, had always had 
a rather feeble digestion, but had recently been doing very 
well on a wet nurse. She had had a " cold in the head " 
about six weeks before. Soon after recovery from this cold, 
which lasted about a week, she began to have paroxysms of 
cough at night and during her naps. The cough disturbed her 
sleep considerably, but not enough to affect her general con- 
dition. She did not cough much when awake, had no nasal 
discharge or fever, did not snore at night or keep her mouth 
open, and nursed well. 

Physical Examination. She was small but fairly nourished 
and of fair color. The anterior fontanelle was 3 cm. in di- 
ameter and level. There was no snuffles and she kept her 
mouth shut. There were no teeth and the gums were not 
inflamed. The fauces were normal. The membranse tym- 
panorum were normal. There was a slight rosary. The 
heart, lungs and abdomen were normal. The liver was 
palpable 2 cm. below the costal border in the nipple line. 
The spleen was not palpable. The extremities were normal. 
There was no spasm or paralysis; the knee-jerks were equal 
and normal. The cervical lymph nodes w^ere slightly enlarged. 

Diagnosis. The physical examination shows nothing in 
the nose, fauces or chest to account for the cough. There are 
no evidences of otitis media, difficult dentition or disturbance 
of digestion, all of which are sometimes said to be causes of 
reflex cough. A " nervous " cough probably does not occur 
at this age. Nevertheless, she coughs, and there must be 
some cause for it. This cause will probably be found in the 
nasopharynx, the only region not investigated in the physical 
examination, in spite of the absence of all of the symptoms of 
adenoids common in older children. An examination of the 

153 



154 CASE HISTORIES IN PEDIATRICS. 

nasopharynx then showed a small amount of soft Adenoids, 
not sufficient to interfere in any way with respiration. Ade- 
noids of this sort, however, if inflamed, will often secrete just 
enough fluid to keep up a constant tickling of the throat and 
cough when the baby is asleep. They are one of the most 
common causes of persistent cough in infancy. 

Prognosis. Removal of the adenoids will stop the cough at 
once. 

Treatment. It is hardly worth while to waste time on 
palliative measures, such as applications to the nasopharynx 
through the nose or mouth, when operation will remove the 
cause at once and hence cure the cough. The operation is a 
simple one and not at all dangerous. There is, moreover, a 
certain amount of risk in leaving the adenoids in situ, because 
they are often the starting point of attacks of rhinitis and 
otitis media and, if they increase in size, will cause obstruction 
to nasal respiration. It is true that they may grow again but, 
if they do, they can be removed again. In the meantime, the 
baby is relieved of its symptoms and freed from the dangers 
to which adenoids expose it. 



NOSE, THROAT, EARS AND LARYNX. 1 55 

CASE 49. John W., twenty-five months old, had always 
had a rather feeble digestion and been backward in develop- 
ment. He had taken less and less solid food during the last 
three months, and for the last month had refused everything 
but liquids. Swallowing seemed to trouble him. He did not 
vomit, had no flatulence or hiccough, and had one small, 
normal movement daily. He had lost considerable weight, 
strength and color during the past month. He had no cough 
or nasal discharge, kept his mouth shut and did not snore at 
night. There had been no fever. 

Physical Examination. He was fair-sized, but flabby and 
pale. The anterior fontanelle was not quite closed. There was 
no nasal discharge. The membranae tympanorum were nor- 
mal. He kept his mouth shut. He had twenty teeth. His 
tongue was clean. The tonsils were somewhat enlarged, but 
not inflamed. There was a slight rosary. The heart and lungs 
were normal. The liver was palpable 2 cm. below the costal 
border in the nipple line. The spleen was not palpable. The 
abdomen was rather large and lax, but otherwise normal. 
The extremities were normal. There was no spasm or paraly- 
sis; the knee-jerks were equal, but rather feeble; there was 
no Kernig's sign. There was no enlargement of the peripheral 
lymph nodes. 

Diagnosis. The rosary shows that he has, or has had, a 
certain amount of rickets. The open fontanelle and large 
abdomen are probably also manifestations of the same dis- 
ease. The flabbiness and pallor are presumably due to an 
insufficient supply of food. The unwillingness to eat can 
hardly be due to loss of appetite from indigestion because 
there are no other symptoms of indigestion. The enlargement 
of the tonsils seems hardly great enough to interfere mechani- 
cally with the swallowing of solid food. There must be, 
therefore, some other cause. This will probably be found in 
the nasopharynx, as Adenoids in some way often make 
swallowing difficult. Examination of the nasopharynx with 
the finger showed a large mass of firm adenoids situated 
posteriorly, so that they did not interfere with respiration. 
In the absence of any other explanation it is almost certain 
that the adenoids, or the adenoids and the enlarged tonsils 



I56 CASE HISTORIES IN PEDIATRICS. 

together, make the swallowing of solid food so uncomfortable 
that he is unwilling to take it. In consequence, he is taking 
an insufficient amount of nourishment and this, in turn, is 
the cause of the progressive failure. 

Prognosis. The removal of the tonsils and adenoids will 
soon be followed by willingness to take solid food. When he 
begins to take a proper amount of nourishment he will soon 
regain his weight, strength and color. 

Treatment. The treatment is the immediate removal of 
the tonsils and adenoids. 



NOSE, THROAT, EARS AND LARYNX 1 57 

CASE 50. George T., thirteen months old, began to refuse 
his food February 24. He was feverish and lost weight 
rapidly. He took his food very poorly, but did not vomit and 
his dejections were normal. He had a frequent, painful 
cough. There was no nasal discharge. He was sent to the 
Infants' Hospital February 28 with the diagnosis of bronchitis. 

Physical Examination. He was fairly developed and nour- 
ished. He was pale, but not cyanotic. The general appear- 
ance was that of sepsis. The anterior fontanelle was 3 cm. 
in diameter and level. There was slight pufhness about the 
eyes. There was a considerable general, soft, non-fluctuant 
swelling in the right neck, extending forward from about the 
angle of the jaw to just beyond the median line and downward 
over the clavicle. The alae nasi moved with respiration. 
There was no nasal discharge. He held his head slightly 
extended and kept his mouth open. His throat was full of 
thick mucopurulent material which rendered inspection 
difficult. The right tonsil was moderately enlarged and some- 
what reddened. The respiration was somewhat difficult, but 
not noisy. His cry was clear. There was no retraction of the 
suprasternal, supraclavicular or intercostal spaces. Per- 
cussion of the lungs showed nothing abnormal. Respiration 
was normal in character but diminished in intensity. Numer- 
ous medium and coarse moist rales were heard throughout 
both chests, both back and front. They were exactly alike 
on both sides. The same sounds were heard under the upper 
part of the sternum and in the middle of the back. The 
abdomen showed nothing abnormal. The liver was just 
palpable in the nipple line. The spleen w T as not palpable. 
The extremities showed nothing abnormal. There was no 
spasm or paralysis. The knee-jerks were equal and normal. 
There was no Kernig's sign. The rectal temperature was 
104.5 F., the pulse 150, the respiration 35. 

The urine was high in color, acid in reaction, of a specific 
gravity of 1,020, and contained no albumin or sugar. 

The leucocyte count was 30,000. 

Diagnosis. The quiet respiration and the clear cry show 
that there is no trouble in the larynx. The facts that the 
rales are alike on both sides, both back and front, and that 



158 CASE HISTORIES IN PEDIATRICS. 

the same sounds are heard under the manubrium and in the 
middle of the back show that they are made high up and 
transmitted downward through the bronchi, and not made 
in the chest. This, of course, rules out bronchitis. The high 
temperature, the marked leucocytosis and the general appear- 
ance of sepsis point very strongly to a focus of pus somewhere. 
The soft, non-fluctuant character of the swelling in the neck 
is not consistent with an external abscess. The swelling of 
the tonsils is not as much as would be expected if there was a 
peritonsillar abscess. The unwillingness to take food, the 
pufhness of the eyes, the swelling of the neck, the position of 
the head and the prominence of the tonsil all suggest an 
inflammatory process in the nasopharynx. The collection of 
pus is, therefore, probably in the nasopharynx; that is, there 
is almost certainly a Retropharyngeal Abscess. It is 
noted in the physical examination that, on account of the 
large amount of mucopurulent material in the throat, inspec- 
tion was difficult, and, therefore, presumably unsatisfactory. 
In such cases inspection alone is not sufficient and will often 
fail to reveal serious conditions. The throat should always 
be palpated when inspection is not perfectly satisfactory. 
Palpation, in this instance, showed that the right side of the 
pharynx was filled by a tense, elastic swelling which extended 
downward to the level of the larynx and pushed the tonsil 
forward, thus confirming the diagnosis of retropharyngeal 
abscess. 

Prognosis. The prognosis is grave even if the abscess is 
opened at once, as it should be, because the baby is in poor 
condition and generally septic and may not be able to rally 
even when the source of infection is removed. 

Treatment. The treatment is to open the abscess at once. 
It is not safe to leave it alone, because if it does not rupture of 
itself it interferes with deglutition and respiration and there 
is constant absorption from the abscess, and if it does open 
itself there is danger of suffocation from the sudden dis- 
charge of pus or of a secondary inhalation bronchopneu- 
monia. It is far better to open it through the mouth than 
from the outside. The best way to open it is with a knife, 
guarded .except at the point, passed along the finger as a 



NOSE, THROAT, EARS AND LARYNX. 1 59 

guide. A gag must not be used, because, if the mouth is 
opened too widely, sudden death may result from the pressure 
of the abscess on the pneumogastric nerve. The mouth can 
be held sufficiently wide open with the finger or a tongue 
depressor. The incision is best performed with the patient in 
the upright position. If he is tipped fonvard the instant the 
incision is made, there is no danger of pus entering the air 
passages. The incision must be opened up widely with the 
finger in order to insure the thorough emptying of the ab- 
scess cavity. The abscess should be squeezed once or twice 
daily with the finger to keep up the drainage and to prevent 
the opening from closing. It will be well to wash out the 
mouth several times daily with some mild alkaline solution. 
If he does not take his food well he must be fed with a tube, 
introduced through the mouth. No stimulation is necessary 
at present. 



l6o CASE HISTORIES IN PEDIATRICS. 

CASE 51. John R., six months old, began to have a 
slight " cold in the head " February 15, but had no other 
symptoms. Three days later he was taken suddenly sick with 
fever, cough and difficulty in breathing. He lost his appetite, 
but showed no other symptoms of gastro-enteric disturbance. 
Swallowing seemed to cause discomfort. He apparently had 
no pain and did not put his hand to his ear. He was taken to 
a physician, February 21, who found the rectal temperature 
104. 2° F., the pulse 160 and the respiration 52. He sent the 
baby to the Infants' Hospital with the diagnosis of pneumonia. 
He was not seen and examined until the next day. 

Physical Examination. He was a large, fat baby. His 
color was good. He took considerable interest in his sur- 
roundings. The alse nasi did not move and the respiration 
was not grunting or painful, even when he cried. The 
anterior fontanelle was 3 cm. in diameter and level. There 
was no tenderness on pressure over the mastoids. There was 
no rigidity of the neck. The pupils were equal and reacted to 
light. There was a slight nasal discharge. The tongue was 
moderately coated. The throat was slightly reddened, but 
otherwise normal. The heart and lungs were normal. The 
liver was palpable 2 cm. below the costal border in the nipple 
line. The spleen was not palpable. The extremities were 
normal. There was no spasm or paralysis. The knee-jerks 
were equal and lively. There was no Kernig's sign. There 
was no enlargement of the peripheral lymph nodes. The 
rectal temperature was ioo° F., the pulse 115, the respiration 

38. 

The urine was pale, clear, acid in reaction, of a specific 
gravity of 1,012 and contained no albumin. 

Diagnosis. The acute onset with fever, cough and diffi- 
culty in breathing and the relatively greater increase in the 
rate of the respiration over that of the pulse point strongly to 
pneumonia. His general appearance, the absence of motion 
of the alse nasi and of grunting and painful respiration, the 
drop in the temperature and the normal condition of the 
lungs, while they do not exclude pneumonia, make it very 
improbable. Some other cause for the symptoms must be 
sought. The only place which has not been investigated is 



NOSE, THROAT, EARS AND LARYNX. l6l 

the ear. The absence of pain, putting the hand to the ear and 
tenderness on pressure over the mastoids, does not count at 
all against otitis media. Pain is often absent in this disease. 
Babies seldom put their hands to their ears when they have 
otitis media and often do under other conditions. Tenderness 
over the mastoids is extremely rare in middle-ear disease at 
this age. Examination of the ears showed marked redness 
and some bulging of the right, and slight reddening of the 
left membrana tympani, showing that the trouble was 
Otitis Media. 

Prognosis. The prognosis is good both as to life and the 
maintenance of normal hearing if the proper treatment is 
carried out. If the ear is opened early and proper drainage 
secured, extension to the mastoid, sinuses or meninges very 
seldom occurs at this age. If the drum is opened before it 
ruptures, it usually heals without a scar and leaves the hear- 
ing unimpaired. 

Treatment. The right drum should be opened at once. 
The left should not be touched at present. Both ears should 
be syringed three or four times daily with warm water. 



1 62 CASE HISTORIES IN PEDIATRICS. 

CASE 52. Joseph B., twenty- two months old, was seen 
in consultation July 22. He lived in a malarial district. He 
had always been delicate and pale. He had had a cough and 
a slightly elevated temperature since an attack of bronchitis 
in the early spring. He had seemed worse and the tempera- 
ture had been higher and more irregular during the last two 
weeks. He had had a chill the night before, which was fol- 
lowed by a temperature of 105 F. and sweating. His appe- 
tite had been poor, but there had been no symptoms of indi- 
gestion, and the movements had been normal. Nothing 
abnormal had been found on physical examination except 
pallor and a slight enlargement of the spleen. The urine had 
shown nothing abnormal. An almost positive diagnosis of 
malaria had been made on the basis of the chill, fever and 
sweating, the enlargement of the spleen, the pallor and the 
apparent absence of any other cause for the symptoms. 

Physical Examination. He was small and only fairly 
nourished. Pallor was marked. The anterior fontanelle was 
closed. He had twelve teeth. There was a slight nasal dis- 
charge and there was a little mucopurulent secretion in the 
nasopharynx. His tongue was moderately coated. There 
was a slight rosary. The heart and lungs were normal. The 
abdomen was rather large but lax. The liver was palpable 
2 cm. below the costal border in the nipple line. The spleen 
was palpable 3 cm. below the costal border. The extremities 
showed nothing abnormal. There was no spasm or paralysis. 
The knee-jerks were equal and normal. Kernig's sign was 
absent. There was a slight general enlargement of the 
peripheral lymph nodes. 

The urine was pale, clear, slightly acid in reaction, of a 
specific gravity of 1,015 an d contained no albumin or sugar. 
The sediment showed no formed elements. 

Blood. 

Hemoglobin, 42% 

Red corpuscles, 4,560,000 

White corpuscles, 30,000 

Small mononuclears, 45-5% 

Large mononuclears, 6.0% 

Polynuclear neutrophiles, 47-5% 

Eosinophils, 1 .0% 



NOSE, THROAT, EARS AND LARYNX. 1 63 

There was much variation in the size and shape of the red 
corpuscles, but no nucleated forms were seen. No plasmodia 
malariae were seen. 

Diagnosis. The leucocytosis and the absence of plasmodia 
at once exclude malaria. The rosary means a slight but 
unimportant amount of rickets. The blood has the character- 
istics of secondary anemia in infancy. The enlargement of 
the spleen is probably due to the same cause as the anemia. 
The continued irregular temperature and the chill suggest 
tuberculosis or confined pus. Tuberculosis at this age is 
rarely accompanied by chills, and it is unusual to have a high, 
irregular temperature without some physical signs of tubercu- 
losis. Tuberculosis is, however, the most probable diagnosis 
unless some other cause for the symptoms can be found. The 
most common locality for confined pus in infancy, when it 
is not discovered on a routine examination, and when the urine 
is normal, is the middle ear. The nasal discharge and the 
mucopurulent secretion in the nasopharynx suggest, in this 
instance, the possibility of an infection of the middle ear. 
An examination of the ears showed bulging and reddening of 
both membranse tympanorum. Paracentesis showed pus in 
both middle ears. The diagnosis is, therefore, Otitis Media. 

Prognosis. The prognosis is good. The temperature will 
gradually work down to normal and the general condition 
improve. There is but little chance of extension to the mas- 
toid cells or to the sinuses. Hearing will probably not be 
impaired. 

Treatment. Now that the ears have been opened, the 
treatment is syringing with warm water, three or four times 
daily, until the discharge has ceased and the incisions have 
healed. 



I64 CASE HISTORIES IN PEDIATRICS. 

CASE 53. Jennie C. was the first child of healthy parents. 
She was born after a normal labor, was nursed for six months 
and did well. When six months old she was said to have had 
pneumonia and some brain trouble with it; at any rate, she 
had convulsions. During and since this illness she had been 
fed on Horlick's Malted Milk, prepared with water. She had 
lost weight, had vomited occasionally and had had a dozen or 
more small, green, watery movements daily. Her nose was 
always stopped up. She kept her mouth open and had con- 
siderable cough. For two weeks she had had many attacks 
daily in which she made a crowing sound, held her breath and 
got black in the face. During the last week several of these 
attacks had terminated in convulsions. She was seen when 
seven months old. 

Physical Examination. She was fairly developed and nour- 
ished. The anterior fontanelle was 5 cm. in diameter, but 
level. There was no craniotabes. The head was of good 
shape. The eyes were rather prominent. She was bright and 
intelligent. The pupils were equal and reacted to light. 
The nares were partially occluded and the mouth was kept 
open. The throat showed nothing abnormal on either in- 
spection or palpation. An attempt to introduce the finger 
into the nasopharynx was unsuccessful. The tongue was 
dry and considerably coated. There were no teeth. There 
was a marked rosary. She held up her head, but was unable 
to sit alone. The heart and lungs were normal. The abdomen 
was rather large and lax. The lower border of the liver was 
palpable 3 cm. below the costal border in the nipple line. 
The spleen was not palpable. There was slight enlargement 
of the epiphyses at the wrists. There was no spasm or paraly- 
sis of the extremities. The knee-jerks were equal and lively. 
There was no Kernig's sign. During the examination she 
started to cry, then drew in her breath with a crowing noise, 
stopped breathing and became moderately cyanosed. After 
perhaps a minute she began to breathe again and her color 
quickly became good. The mother said that this attack was 
a very mild one and not nearly as severe as many. 

Diagnosis. The condition here is a complicated one. She 
undoubtedly has a chronic intestinal indigestion as the result 



NOSE, THROAT, EARS AND LARYNX. 1 65 

of improper feeding. She also has a moderate amount of 
rickets. This is proved by the marked rosary and the en- 
largement of the epiphyses at the wrists. Other abnormalities 
which are presumably signs of rickets are the large fontanelle, 
the delayed dentition and the lax abdomen. She has, in 
addition, a chronic rhinitis and presumably adenoids, al- 
though this is not proven, since the attempt to examine the 
nasopharynx was unsuccessful. 

The most important conditions, however, at any rate in the 
opinion of the parents, are the attacks of asphyxia and the 
convulsions. These attacks are so characteristic of the con- 
dition known as Laryngismus Stridulus that a differential 
diagnosis is hardly necessary. The diseases which might 
possibly be confused with it are congenital laryngeal stridor, 
catarrhal laryngitis and laryngeal diphtheria. Congenital 
stridor is present at birth, or develops soon after, is constant 
instead of being paroxysmal and is not accompanied by 
cyanosis. The attacks of difficult respiration in catarrhal 
laryngitis occur less frequently and usually only at night, are 
of longer duration and the breath is never held in them. 
The difficulty with respiration in laryngeal diphtheria is 
constant and progressive and the breath is not held. 

Laryngismus stridulus is not properly a disease, but merely 
a manifestation of the spasmophilic diathesis. In this dis- 
ease there is a marked increase in the nervous excitability, 
which shows itself in various ways, the most characteristic 
manifestations being laryngismus stridulus, tetany and 
convulsions. The convulsions in this instance are undoubt- 
edly merely another manifestation of this diathesis. It is 
almost certainly due to some disturbance in the metabolism 
of calcium. It is uncertain whether this disturbance is or is 
not due to parathyroid insufficiency. There is in all proba- 
bility a deficiency of calcium salts in the blood in the spas- 
mophilic diathesis. It is very possible that her food during 
the past month contained an insufficient amount of calcium, 
or contained it in a form not easily utilized. The rickets is to 
be regarded, therefore, merely as another manifestation of 
the disturbance of nutrition from the unsuitable food and 
not as the cause of the paroxysmal attacks. The rhinitis and 



1 66 CASE HISTORIES IN PEDIATRICS. 

adenoids can have no direct etiological connection with the 
attacks, but may possibly act as exciting causes through 
reflex irritation. 

Prognosis. The immediate prognosis of the attacks is, 
on the whole, good, but must be guarded, because babies do 
sometimes die in these attacks. The prognosis in general de- 
pends very largely on whether or not she can get the best 
treatment. If she can, recovery will be rapid ; if she cannot, 
the chances are rather against her. 

Treatment. The immediate treatment of an attack is to 
slap her on the back or to dash cold water on her face or chest. 
Artificial respiration is sometimes necessary. Most attacks 
will, however, cease quickly if nothing is done. Bromide of 
soda, in doses of from three to five grains, in an aqueous solu- 
tion, three or four times daily, will tend to diminish the 
frequency of the paroxysms. 

The treatment of the spasmophilic diathesis, and at the 
same time of the intestinal indigestion and rickets, consists 
in regulation of the diet. Human milk always quickly re- 
lieves this condition. A purely carbohydrate diet relieves it, 
but much less promptly and is, moreover, not suitable for a 
baby of this age. A return to cow's milk in any form, at any 
rate until a considerable time has elapsed, almost invariably 
causes a return of the symptoms. The only rational food for 
this baby is, therefore, human milk. If she cannot get it she 
must be given a starch and sugar solution for as long a time 
as is possible, due regard being paid to her general condition, 
and then quickly worked on to some modification of cow's 
milk. 

It is possible that the administration of some of the calcium 
salts, like the lactate, may do good. The indications are so 
doubtful and the results to be expected so slight compared 
with those obtained from human milk that they are, however, 
hardly worthy of consideration. Parathyroid extract, in 
doses of one twentieth of a grain, three times daily, would 
seem a more rational treatment, but has not as yet been used 
enough to prove whether or not it is of benefit. 



NOSE, THROAT, EARS AND LARYNX. l6j 

CASE 54. Mary S., four years old, had had a slight 
nasal discharge and seemed a little feverish all day. She went 
to bed feeling fairly well, however, after eating her usual 
supper. Soon after going to sleep she began to cough from 
time to time, the cough being dry, hard and metallic. About 
nine o'clock her parents heard her breathing noisily and ap- 
parently struggling in her sleep. When they got to her they 
found her sitting up in bed moderately cyanosed and breath- 
ing with much difficulty. Inspiration was noisy and difficult, 
expiration quiet. She occasionally gave a short, dry, metallic 
cough. She tried to cry out, but could not raise her voice 
above a whisper. At times she clutched at her throat. She 
was seen at 9.30 p.m. 

Physical Examination. She was then breathing quietly 
and her color was good. Her voice was hoarse and her cough 
metallic. There was a slight nasal discharge and the throat 
was a little reddened. The heart, lungs and abdomen were 
normal. The liver and spleen were not palpable. The 
extremities showed nothing abnormal. There was no spasm 
or paralysis. The knee-jerks were equal and lively. Kernig's 
sign was absent. There was no enlargement of the peripheral 
lymph nodes. The rectal temperature was 101° F. 

Diagnosis. The only diseases to be considered are laryn- 
geal diphtheria and catarrhal laryngitis with " spasmodic 
croup." The sudden onset and the short duration of the 
difficulty in respiration positively rule out laryngeal diph- 
theria, in which the onset is slow and the difficulty in respira- 
tion steadily increases without intermissions. The history 
of the nasal discharge during the day and the occurrence of 
the attack in the early evening are also very characteristic of 
" spasmodic croup." The diagnosis is, therefore, Catarrhal 
Laryngitis with " spasmodic croup." 

Prognosis. There is, of course, no danger as to life. She 
may or may not have another attack during the night. She 
is likely to have paroxysms the next two or three nights 
unless they are prevented by treatment. Having had " spas- 
modic croup " once, she is likely to have it for the next few 
years whenever she " catches cold." 

Treatment. This attack is a mild one and does not require 



1 68 CASE HISTORIES IN PEDIATRICS. 

very active treatment. She should have twenty drops of the 
wine of ipecac and ten drops of paregoric at once, and ten 
drops of the wine of ipecac and five drops of paregoric every 
hour for two or three doses, the object being to relax, but not 
to nauseate her. A " croup kettle " or a dish of boiling water 
in the room will moisten the air and will aid in preventing the 
recurrence of the paroxysms. The temperature of the room 
should be kept at about 64 F. She should be kept in the 
house or, if feverish, in bed for the next three or four days, and 
should be given ten drops of the wine of ipecac every hour, 
beginning at 3 p.m., until bedtime, each afternoon. If the 
paroxysms recur, the treatment recommended for to-night 
should be repeated. 



SECTION VI. 

DISEASES OF THE BRONCHI, LUNGS AND PLEUR/E. 

CASE 55. John J. ? three years old, started in with a 
" cold in his head " and cough, January 10. The nasal dis- 
charge diminished and the cough became drier on the 12th. 
He did not seem at all sick until the 13th. The cough was 
then much more severe and apparently painful. His appe- 
tite was poor and he appeared feverish. 

Physical Examination. He was well developed and nour- 
ished. His cheeks were flushed. There was a slight nasal 
discharge. The ear drums were normal. The whole throat 
was moderately reddened, but there was no enlargement of 
the tonsils and no exudation. His tongue was slightly coated. 
The lungs showed nothing abnormal except a few sibilant and 
sonorous rales scattered throughout both chests, both back 
and front. The heart was normal. The abdomen was normal. 
The liver and spleen were not palpable. The extremities 
were normal. There was no spasm or paralysis. The knee- 
jerks were equal and normal. There was no enlargement of 
the peripheral lymph nodes. The rectal temperature was 
100. 8° F., the pulse 132, the respiration 34. 

Diagnosis. The diagnosis is, of course, Bronchitis. 

Prognosis. The prognosis at present is perfectly good. 
The only danger is of a consecutive bronchopneumonia. 
This ought not to develop if he has proper care and treatment. 

Treatment. The treatment of bronchitis depends on the 
stage of the bronchitis and the condition of the bronchial 
mucous membrane. The bronchitis in this instance is in the 
early stage. The bronchial mucous membrane is congested, 
dry, swollen and reddened, and consequently there is but 
little secretion. The object of the treatment at this stage is 
to relax the mucous membrane and in this way increase the 
secretion. The drugs which will do this are the so-called 

169 



170 CASE HISTORIES IN PEDIATRICS. 

" sedative " expectorants. These are tartar emetic, apo- 
morphin and ipecac. The only one of these which is safe 
to give to children is ipecac. This may be given as the wine 
or syrup. It should be given in water, not mixed with syrups, 
which are inert and disturb the digestion. The object of the 
ipecac is to cause relaxation of the mucous membrane, not 
nausea or vomiting. From five to ten drops every two hours 
is about the right dose for this boy. The alkalies have some- 
what the same action and may be used instead of ipecac. 
A moist atmosphere also tends to moisten and relax the 
bronchial mucous membrane. It will be well, therefore, to 
have a vessel of boiling water ora" croup-kettle " near him. 

The object of the sedative expectorants is to relax the 
bronchial mucous membrane and in this way to hasten the 
cure of the disease. Their dosage and the length of time that 
they are given must be regulated by the condition in the 
bronchi, as revealed by physical examination. They are not 
given for the symptom, cough, and in using them, therefore, 
the amount of coughing must not be considered. The symp- 
tom, cough, is best controlled by some preparation of opium. 
The safest form of opium for a child is paregoric. This boy 
may have from five to fifteen drops every two or three hours 
for the cough if it is troublesome. This also should be given 
in water, not in syrup. The ipecac and paregoric must not be 
combined in the same prescription, because they are given for 
entirely different purposes, and it is necessary to be able to 
give either one without giving the other. He needs the 
ipecac constantly; he may need the paregoric only occasion- 
ally. 

It will be well to give him a tablespoonful of castor oil, or 
one or two teaspoonfuls of syrup of senna at once. The diet 
should be liquids and soft solids. It will be much wiser for 
him to stay in bed. He should have plenty of fresh air, but 
will probably be more comfortable if the temperature does 
not go below 6o° F. 



DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 171 

CASE 56. Mary J., nine months old, had always been a 
well, strong baby. She began to have a little running from 
the nose March i. March 3 she began to cough a good deal 
and to have a little fever. March 4 she had more fever, 
coughed a great deal and had considerable rattling in the 
chest. She took but little food, but digested that little well. 
She grew rapidly worse and was seen in consultation the 
night of March 5. 

Physical Examination. She was well developed and nour- 
ished, but markedly cyanotic. The alse nasi moved with 
respiration. She was unable to lie down and was very rest- 
less. The examination was superficial because of her critical 
condition. The throat showed nothing abnormal. The 
cardiac area was not determined ; the action was regular, the 
sounds feeble. There was sinking in of the supraclavicular 
and lower intercostal spaces, as well as of the epigastrium, 
with each inspiration. There was vesicular resonance all 
over the lungs. The respiratory sound was feeble, but normal 
in character. The vocal resonance was not determined. 
Both chests were full of fine and medium moist rales, the fine 
predominating. The rales were easily palpable. The ex- 
tremities were cold and the whole body covered w T ith perspira- 
tion. The temperature was not taken. The pulse was faster 
than could be counted. The respiration was 80. 

Diagnosis. The diagnosis is, without question, Bronchitis. 
The finer and medium-sized tubes are involved to a much 
greater degree than the larger. 

Prognosis. The condition is a very critical one and, while 
not hopeless, the chances are very much against recovery. 
She will probably not live twenty-four hours. If she does, 
her chances are somewhat better. 

Treatment. Her condition is critical and the treatment 
must be immediate and energetic. The first indication is to 
clear out the bronchial tubes. Alternate dippings in water 
from 105 F. to no° F. and from 65 F. to 75 F., as is done 
in resuscitating new-born infants, will probably make her cry, 
breathe deeply and cough, and in this way get rid of the 
excessive secretion. If this method is not successful, the wine 
or syrup of ipecac, in teaspoonful doses, will make her vomit 



172 CASE HISTORIES IN PEDIATRICS.- 

and in this way clear out the bronchial tubes. She must then 
be given plenty of fresh air and, if necessary, oxygen. The 
oxygen is given for the symptom, cyanosis, and must be given 
continuously as long as the cyanosis lasts, not intermittently 
as it usually is. The dippings and ipecac may be repeated as 
necessary. It must not be forgotten, however, that ipecac 
used in this way is depressing and, consequently, a dangerous 
remedy. If the dippings and ipecac do not relieve her, atropin, 
in doses of 1-500 grain, may be given subcutaneously with the 
object of diminishing the secretion. 

She also needs immediate stimulation. Strychnia is a 
respiratory as well as a cardiac stimulant and is, therefore, 
doubly indicated. It should be given subcutaneously, in 
doses of 1-300 grain, every two or three hours, as necessary. 
Caffeine-sodium benzoate, or salicylate, in doses of from 
one eighth to one fourth of a grain, given subcutaneously, 
will also aid in keeping up the heart. 

She should be fed every two hours, and will probably not 
take more than an ounce at a time, if she does that. She will 
probably not be able to take the bottle. The best way to 
give the food is with a Breck feeder. If she will not take it 
in this way, a dropper or spoon may be tried. Human milk 
is the best food for her; next to this, a weak modified milk, 
for example, one containing 2% of fat, 6% of sugar, 0.75% of 
whey proteids and 0.25% of casein. 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA. 1 73 

CASE 57. Lizzie O., four years old, began to cough early 
in April. She began to whoop in about a week. She was but 
little depressed by the whooping-cough and got on very well 
until about the first of May. The cough then became worse, 
she lost her appetite and failed in flesh and strength. She 
began to be feverish and on May 6 went to bed. From that 
time she grew rapidly worse. She had frequent paroxysms of 
whooping and much cough without whooping. She raised a 
good deal of mucopurulent sputum. She was unable to lie 
down with comfort the night of May 8 and was more or less 
blue. She took almost no nourishment and was very restless. 
She was seen in consultation May 9. 

Physical Examination. She was fairly developed and nour- 
ished but had evidently lost considerable weight. She was 
bolstered up by pillows in a reclining position as she was 
unable to lie flat. There was marked cyanosis of the face and 
extremities. The alae nasi moved with respiration. She ap- 
peared very sick. Examination of the throat showed nothing 
abnormal. There was no retraction of the supraclavicular or 
intercostal spaces, but a little of the epigastrium. The 
cardiac impulse was diffuse; the apex in the fifth space just 
outside the nipple line. The upper border of relative dullness 
was at the lower border of the second rib; the right border 
nearly at the right parasternal line. The first sound was 
short and rather feeble, and at the mitral area was followed by 
a soft blowing murmur. The second pulmonic sound was no 
louder than the second aortic. There was dullness on per- 
cussion in the lower left back below the angle of the scapula, 
and extending outward from the spinous processes to the 
scapular line. In this area the respiration was bronchial in 
character, but diminished in intensity. The vocal resonance 
and fremitus were increased. There were numerous high- 
pitched, fine and medium moist rales. In the right axilla, 
at about the level of the sixth rib, there was an area of dullness 
about the size of a silver dollar. Respiration was here broncho- 
vesicular and accompanied by many fine, moist, high-pitched 
rales. Elsewhere respiration was normal in character, but 
diminished in quantity. There were many medium and 
coarse moist rales throughout both chests. The abdomen 



174 CASE HISTORIES IN PEDIATRICS. 

showed nothing abnormal. The liver and spleen were not 
palpable. The extremities were normal. The knee-jerks 
were equal and normal. There was no edema and no enlarge- 
ment of the peripheral lymph nodes. The rectal temperature 
was 104 F., the pulse 200, and the respiration 88. 

Diagnosis. The signs of bronchitis and the presence of 
two separate areas of solidification in the lungs prove that 
she has a Bronchopneumonia. There is nothing about the 
physical signs to show whether this is or is not tubercular. 
While it is true that whooping cough, more than any other 
disease except measles, predisposes to the development of 
tuberculosis, the infection far more often takes the form of 
a bronchial adenitis than of a bronchopneumonia. Non- 
tubercular bronchopneumonia is very common in whooping 
cough; tubercular, very rare. The chances are, therefore, 
very much in favor of its being non-tubercular. The finding 
of tubercle bacilli in the sputum would, of course, prove 
it to be tubercular; their absence would not exclude tubercu- 
losis. The process is so acute that the skin tuberculin test 
would probably be negative even if it is tubercular. The 
white blood count would not help because, even if the broncho- 
pneumonia is primarily tubercular, there is almost certainly a 
secondary infection which will cause a leucocytosis. It is of 
no importance anyway, in her present condition, to make a 
diagnosis between the two forms, because it will make no 
difference in the treatment. 

The diffuse cardiac impulse, the enlargement of the heart 
upward and to the right, the short, feeble first sound, and the 
diminution of the second pulmonic sound (the second pul- 
monic sound is normally louder than the second aortic at 
this age) show marked weakness and dilatation. The systolic 
murmur at the apex is almost certainly due to a relative in- 
sufficiency of the mitral valve, as there is no reason to suspect 
an endocarditis, and the dilatation of the heart is amply suffi- 
cient to account for an insufficiency. It is impossible to deter- 
mine whether the dilatation of the heart is due to the strain 
of coughing, to a myocarditis in connection with the broncho- 
pneumonia, or to both. The chances are that it is largely 
due to the strain of coughing, which falls on the right side of 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA. 1 75 

the heart, since only the right side of the heart is enlarged, 
while the enlargement is usually more uniform in myocarditis. 
It is very probable, however, that there may be a small 
myocarditic element. 

Prognosis. She is in a very serious condition. She has 
hardly reached the height of her whooping-cough, she has 
bronchopneumonia and her heart is dilated. She has a chance 
of recovery, but only a small one. 

Treatment. The first thing to do is to favor oxygenation 
of the blood by giving her a liberal supply of fresh air. At 
this time of year she may be put out of doors or by the open 
window. If fresh air does not relieve the cyanosis, she must 
be given oxygen. The indication for oxygen is cyanosis. She 
should, therefore, be given oxygen continuously as long as she 
is cyanotic, not intermittently, as is usually done. 

The next indication is to stimulate the heart. Her con- 
dition demands a quick stimulant at once. Sulphate of 
strychnia in doses of 1-120 grain, or caffeine-sodium benzoate 
or salicylate, in doses of one half a grain, repeated every two 
hours to every four hours, as necessary, are the best drugs. 
Aromatic spirits of ammonia, in fifteen-drop doses, may tide 
over an emergency. She also needs a cardiac tonic to 
strengthen and build up the heart wall. Digitalis is the best 
of the cardiac tonics. Five drops of the tincture every four 
hours will be none too much for her at present. If the digitalis 
takes hold, the strychnia and caffein may be diminished or 
omitted. She should be fed every two hours with small 
amounts of milk and soft solids, such as custard, junket, 
smooth cereals, blanc mange and ice cream. 

The results of the treatment of whooping-cough are at 
best most unsatisfactory. To do good, the drugs must be 
given up to their physiological limit. In such doses they will 
certainly do harm in this instance. If the lungs are not too 
much filled up, there is no objection to giving morphia, in 
doses of from one thirty-second to one twenty-fourth of a 
grain, to control excessive cough, nervousness, sleeplessness 
and discomfort. 



Ij6 CASE HISTORIES IN PEDIATRICS. 

CASE 58. Michael D., seven years old, went to school on 
the morning of January 24 perfectly well, as far as was known, 
except that his bowels had not moved for nearly a week. 
While playing at recess one of his playmates struck him in 
the abdomen with his fist. Shortly afterward he became 
faint and nauseated and was sent home by his teacher. He 
vomited soon after reaching home and continued to do so for 
twenty-four hours. He was given two grains of calomel in 
divided doses during the afternoon and night of the 25th, 
and a teaspoonful of Epsom salts the next morning, but his 
bowels had not moved. He continued to complain of nausea, 
headache and pain in the abdomen. The abdominal pain was 
general, not localized. He had coughed a little since the morn- 
ing of the 26th. He had felt very hot, but his temperature had 
not been taken. He had not been delirious. He was seen 
about 4 p.m., January 26. 

Physical Examination. He was fairly developed and nour- 
ished. He was perfectly clear mentally. The cheeks were 
flushed. His face was not pinched. The alae nasi moved with 
respiration. The tongue was moist and moderately coated. 
The throat was slightly reddened, but was otherwise normal. 
The cardiac impulse was in the fifth space, just inside the nip- 
ple line. The right border of dullness was 1 cm. to the right of 
the right sternal border, the upper border at the middle of the 
third rib. The sounds were normal. The second pulmonic 
sound was somewhat the louder. There was slight dullness 
in the right back below the angle of the scapula with slightly 
diminished respiration of normal character. The vocal reso- 
nance and fremitus were normal. There were no rales. The 
upper border of the liver flatness was at the upper border of 
the sixth rib, the lower border was not palpable. The spleen 
was not palpable. The level of the abdomen was considerably 
above that of the thorax; it was everywhere tympanitic. 
There was no muscular spasm, but the whole abdomen was 
somewhat tender, the tenderness being most marked in the 
right iliac fossa. There was, however, no tumor or dullness 
in this region. There were no evidences of free fluid in the 
abdomen. The extremities were normal. There was no 
spasm or paralysis; the knee-jerks were equal and diminished; 



DISEASES OF THE BRONCHI, LUNGS AND PLEUILE. 1 77 

there was no Kernig's sign. There was no enlargement of 
the peripheral lymph nodes. Rectal examination showed 
nothing abnormal beyond a mass of hard feces in the rectum. 
The rectal temperature was 104 F., the pulse 140, the respira- 
tion 60. 

The urine was high in color, extremely acid in reaction, 
and of a specific gravity of 1,030. It contained no albumin or 
sugar, but a large excess of urates. The sediment showed 
nothing abnormal. 

The leucocyte count was 36,000. 

Diagnosis. The history of the acute onset of vomiting 
and pain in the abdomen immediately after a blow in that 
region makes some acute inflammatory condition in the ab- 
domen seem the most obvious diagnosis. The persistent 
constipation, the continuance of the pain and the abdominal 
distention and tenderness all corroborate this diagnosis. 
The greater tenderness in the right iliac fossa points to an 
involvement of the appendix. Further consideration, how- 
ever, makes this diagnosis seem less probable. The absence of 
the pinched face, of free fluid in the abdomen and of muscular 
spasm makes general peritonitis very improbable. The 
absence of localized spasm, tumor and dullness in the right 
iliac fossa and the negative results of the rectal examination 
practically rule out appendicitis. The blow of another small 
boy could hardly rupture any organ, there was no collapse 
and there are no signs of peritonitis, as would be expected if 
any organ had been ruptured fifty-three hours before. The 
condition of the urine also counts against any injury to the 
kidney. The history of constipation before the injury and 
the mass of hard feces in the rectum suggest that constipa- 
tion may be the cause of the abdominal symptoms, and that 
they, and perhaps the blow as well, may be purely coincidences 
and that the real trouble is located somewhere else. 

The cough suggests some trouble in the lungs. It is a well- 
known fact that the pain in pneumonia is often referred by 
children to the abdomen and that distention of the abdomen 
is very common in pneumonia at this age. Localized diminu- 
tion of the respiratory sound is often the earliest sign of pneu- 
monia. When associated with dullness, as in this instance, it 



I7« CASE HISTORIES IN PEDIATRICS. 

is most suspicious. The relative increase in the rate of the 
respiration over that of the pulse (2 J to I instead of the normal 
4 to 1 ) in an acute disease with a high temperature is almost 
pathognomonic of pneumonia. The motion of the alae nasi, 
while it points toward trouble in the respiratory tract, does 
not necessarily mean that that trouble is pneumonia. Mo- 
tion of the alae nasi is, moreover, not uncommon when there 
are inflammatory processes in the abdomen. It is, therefore, 
not of much diagnostic importance in this instance. The 
flushing of the cheeks is merely a sign of fever and is not espe- 
cially suggestive of pneumonia, as is often supposed. The 
diminution of the knee-jerk is of but little importance, but 
nevertheless is another point in favor of pneumonia. The 
high leucocyte count is characteristic of pneumonia, but is 
not inconsistent with an inflammatory process in the abdomen 
and hence is of practically no importance in the differential 
diagnosis. The points in favor of pneumonia are so much 
more numerous and fit together so much better than do those 
in favor of an inflammatory process in the abdomen that a 
positive diagnosis of Pneumonia is justified. The abdominal 
symptoms are presumably in part due to the constipation 
and in part secondary to the pneumonia. The blow was 
purely a coincidence. 

Prognosis. The prognosis of pneumonia in children is, 
on the whole, very good. He is a strong boy and at present 
is not any sicker than he would be expected to be. His 
chances ought to be at least as good as the average. He can 
be confidently expected to recover. A certain number of 
children with pneumonia are unfortunate enough to develop 
empyema. He may or may not be one of these. It is 
impossible to tell. 

Treatment. The most important part of the treatment is 
to give him a large supply of fresh air. All the windows in 
his room should be wide open. He can be protected from the 
wind, if necessary, by a screen. This being January, he must 
be warmly covered and will probably need a cap and heaters, 
perhaps mittens. If he is treated in this way his fever will, 
in all probability, not require any treatment. Applications 
to the chest, whether poultices, cotton jackets or mud, can 



DISEASES OF THE BRONCHI, LUNGS AND PLEURAE. 1 79 

have no effect on the pneumonic process, tend to overheat 
the patient and, if heavy, interfere with the respiration by 
their weight. There are no drugs which have any effect on 
the pneumonic process. His heart is strong. Medicinal 
treatment is, therefore, contra-indicated. 

The vaccine treatment of pneumonia is, in the author's 
opinion, irrational and, consequently, unjustifiable. Cough 
is not likely to be troublesome if he gets plenty of fresh air. 
If it is, and there is no edema of the lungs or bronchitis, 
heroin, in doses of from one twenty-fourth to one twelfth of a 
grain, will probably make him more comfortable and not do 
any harm. He should be fed once in three hours with milk 
and soft solids, such as simple cereals, custard, blanc mange, 
ice cream and milk toast. Care should be exercised in giving 
him milk because of the constipation. 

The constipation will probably be relieved by low enemata 
of suds. If they are not sufficient, high enemata of suds, oil 
or glycerin may be tried. If these are unsuccessful, a table- 
spoonful of castor oil or two teaspoonfuls of syrup of senna 
will probably be effectual. 



ISO CASE HISTORIES IN PEDIATRICS. 

CASE 59. Matthew L., twenty-six months old, had al- 
ways been unusually strong and vigorous, but very nervous 
and excitable. He had had a little " cold in the head " for 
two or three days, but had not seemed at all sick. The appe- 
tite was rather poor, February 19, and consequently he was 
not given as much to eat as usual. His bowels moved nor- 
mally just before he went to bed. He was very restless and 
feverish all night and toward morning vomited several large 
curds of milk. He had a severe convulsion about 8.30 a.m. on 
the 20th . The colon was washed out and a considerable amount 
of well-digested, yellow feces obtained. He was given two 
tablespoonfuls of castor oil, which resulted in three large, 
loose, yellow movements which contained a little undigested 
food. He had no more convulsions, but twitched a little 
from time to time. He coughed occasionally, and moving, 
coughing and crying seemed to hurt him. The rectal tem- 
perature had ranged between 104 F., and 104.5 F. He was 
seen in consultation at 9 a.m., February 21. 

Physical Examination. He was well developed and nour- 
ished. Pallor was marked and there was a slight tinge of 
cyanosis about the lips. He was perfectly conscious, but 
restless and irritable. There was a slight tendency to rigidity 
and he twitched occasionally. There was no stiffness or 
tenderness in the neck. The pupils were equal and reacted to 
light. The alae nasi moved with respiration. The ear drums 
were normal. The tongue was moderately coated. The 
throat was normal. The heart and lungs were normal. The 
liver and spleen were not palpable. The extremities were 
normal. There was no definite spasm of the extremities and 
no paralysis. The knee-jerks were equal and slightly dimin- 
ished. Kernig's sign was absent. There was no enlargement 
of the peripheral lymph nodes, and no eruption. The rectal 
temperature was 104.6 F., the pulse 140, the respiration 70. 
The leucocytes numbered 24,000. 

Diagnosis. The persistence of the high temperature in 
spite of the thorough emptying of the bowels, the practically 
normal character of the movements and the cessation of the 
vomiting rule out all affections of the gastro-intestinal tract. 
The absence of sore throat and eruptions rules out tonsillitis 



DISEASES OF THE BRONCHI, LUNGS AND PLEUR/E. l8l 

and scarlet fever, while the absence of catarrhal symptoms 
and the leucocytosis exclude influenza. The initial convul- 
sion and the persistence of twitching, together with the slight 
tendency to rigidity, suggest, to a certain extent, some form 
of meningitis, more probably the cerebrospinal. The normal 
mental condition and the absence of all physical signs of 
meningeal irritation, unless the twitching and tendency to 
rigidity be such, practically exclude meningitis. An initial 
convulsion, moreover, is not uncommon at the onset of any 
acute disease in childhood, and a high temperature often 
causes twitching and a tendency to rigidity in nervous chil- 
dren. These points do not count much, therefore, in favor 
of meningitis. The continued high temperature, the slight 
cough, the pain on motion, cough and crying, and, more than 
all, the much greater increase in the rate of the respiration 
than in that of the pulse (2 to 1 instead of the normal 4 to 1), 
make the diagnosis of Pneumonia practically certain in 
spite of the absence of physical signs in the lungs. The move- 
ment of the alae nasi, the slight tinge of cyanosis about the 
lips and the diminution of the knee-jerks, although not of 
much importance, are corroborative of this diagnosis, while 
the leucocytosis is consistent with it. 

Prognosis. The prognosis of pneumonia in childhood is 
very good. In infancy, however, it is a far more serious dis- 
ease. This boy has always been strong and well, is in good 
general condition and probably will not have much lung 
involved. The symptoms of nervous irritability do not make 
the outlook any less favorable. The chances are, therefore, 
very much in favor of his recovery. 

Treatment. See Case 58. The windows must be kept 
wide open, day and night. The cool, fresh air will probably 
lower the temperature somewhat, and thus diminish the 
nervous symptoms. If they persist, the temperature must 
be reduced by bathing. The coal-tar products should never 
be used in pneumonia, either to reduce the temperature or 
to relieve nervous symptoms. The temperature needs to be 
reduced, not because it is 104. 6° F., but because in this 
instance this degree of temperature causes nervous symptoms. 
If it did not, it would not be necessary to treat it. Sponge 



1 82 CASE HISTORIES IN PEDIATRICS. 

baths of alcohol and water, equal parts, at 90 F., will prob- 
ably be sufficient to control it. If they do not, fan baths will 
almost certainly be effectual. Fan baths are given in this 
way: The patient is stripped and wrapped in cheesecloth. 
This is then wet with water at ioo° F. and the patient fanned. 
The temperature is reduced by the evaporation of the water. 
The cheesecloth is wet from time to time as the water evapo- 
rates. Children seldom object to this form of bath. If this is 
ineffectual, he may be given a cold pack at from 6o° F. to 
70 F. Children seldom bear tub baths well, and it is, as a 
rule, wiser not to use them. If necessary, he may be given 
sodium or potassium bromide, in doses of from three to five 
grains, from time to time. There is no indication for stimula- 
tion at present. 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA. 1 83 

CASE 60. David K., eight years old, had had the measles 
when a baby. Since then he had always been well. August 
20 he began to complain of a little pain in his lower left chest, 
which was worse when he ran or played. August 22 he began 
to have a little cough, which was dry and not accompanied 
by pain. After the beginning of the cough the pain in the 
chest ceased, his appetite became poor and he acted weak 
and tired. His mother said that he wanted to sit alone by 
himself instead of playing with the other children. She 
thought that he had been feverish and said that he had sweat 
profusely at night. He was first seen August 30. 

Physical Examination. He was well developed and nour- 
ished, but somewhat pale. There was no dyspnea, except on 
exertion. The tongue was moist with a moderate white coat 
in the center. The throat was normal. The cardiac impulse 
was visible in the fourth space in the left parasternal line. 
The right border of the relative cardiac dullness was about 
two thirds of the distance from the right border of the sternum 
to the right nipple. The upper border of the relative cardiac 
dullness was at the lower border of the second rib. The heart 
sounds were normal in character, but louder to the right of 
the sternum than to the left. The second pulmonic sound 
was considerably louder than the second aortic. The left 
chest moved somewhat less in respiration than the right. 
The intercostal spaces were the same on both sides. There 
was dullness in the left back from the spine to the angle of 
the scapula, below which there was flatness. The whole left 
axilla was flat. There was dullness in the left front from the 
upper border of the third rib to the upper border of the fourth 
rib, below which there was flatness. There was dullness in 
Traube's space. The respiration was loud and bronchial 
below the upper level of dullness, both in back and in front. 
The voice sounds were increased; the vocal fremitus dimin- 
ished. No rales were heard. Above the level of dullness the 
respiration and voice sounds were normal in character and a 
few fine moist rales were heard. There was a marked sense of 
resistance over the dull and flat areas. There was exaggerated 
vesicular resonance over the whole right chest. The respira- 
tion was loud and distinctly puerile. The voice sounds and 



1 84 CASE HISTORIES IN PEDIATRICS. 

fremitus were normal. No extraneous sounds were heard. 
The upper border of the liver flatness in the nipple line was at 
the upper border of the seventh rib. The lower border of the 
liver was palpable 2 cm. below the costal border. The spleen 
was not palpable. The dullness was not determined because 
of the dullness in the left chest. The abdomen showed noth- 
ing abnormal. The extremities were normal. There was no 
spasm or paralysis and the knee-jerks were equal and normal. 
There was no enlargement of the peripheral lymph nodes. 
The mouth temperature was 101.2 F., the pulse 130 and the 
respiration 48. 

Diagnosis. The trouble is, of course, located in the left 
chest. The only question is whether there is solidification of 
the lung or an effusion into the pleural cavity. If the trouble 
is in the lung, it is, judging from the history, more probably 
tubercular than pneumonic. The diminution in the motion 
of the left chest and the mere presence of dullness or flatness 
are of no importance in differential diagnosis. The points 
in favor of solidification of the lung are the normal level of 
the intercostal spaces, the loud bronchial respiration and the 
increased voice sounds. The intercostal spaces are, however, 
often level in childhood, even when there is considerable 
fluid in the pleura, because the elastic chest gives as a whole, 
while in the adult the rigid chest wall does not give and the 
intercostal spaces yield. Theoretically, the respiration and 
voice sounds ought not to be transmitted through fluid; 
practically, they often are in childhood. The explanation is 
presumably to be found in the elasticity of the thoracic wall 
at this age. The bronchial character of the respiration in 
pleural effusion is due to the compression of the lung. The 
points in favor of consolidation of the lung are, therefore, not 
as important as they at first appear. 

The points in favor of a pleural effusion are the distribution 
of the dullness and flatness, which follows gravity rather than 
the lobes of the lung, the displacement of the heart to the 
right, the dullness in Traube's space (which means depres- 
sion of the diaphragm), the diminished fremitus, the absence 
of rales and the marked sense of resistance. The distribution 
of the dullness and flatness is not of quite as much importance 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA. 1 85 

in this instance as it usually is, because the trouble, being- 
tubercular, would not be as likely to be lobar in its distribu- 
tion as would a pneumonia. It may be argued that, if the 
diaphragm is depressed, the spleen ought to be palpable. 
The location of the spleen is such, however, that depression 
of the diaphragm does not displace it. The displacement of 
the heart and diaphragm is positive proof of the presence of a 
pleural effusion. The marked sense of resistance is almost 
positive proof of effusion, as this is practically never felt to 
the same extent over a solid lung. The diminished fremitus 
and the absence of rales are of much less importance, as they 
can be explained in other ways. 

The accentuation of the second pulmonic sound is, of course, 
due to the increased pressure in the pulmonary circulation. 
The physical signs in the right chest are characteristic of 
compensatory emphysema. The upper border of the liver 
flatness is as much below the normal level as the lower border 
is below the costal margin, showing that the liver is not 
enlarged, but merely displaced downward. 

The next point to be decided is whether the effusion is 
serous or purulent. The effusion in this instance is, judging 
from the history, primary, that is, it is not secondary to some 
other acute disease. Primary pleurisy at this age is almost 
always serous; secondary, almost always purulent. The 
sweating is merely a sign of weakness and does not count at 
all in favor of a purulent effusion. The temperature is con- 
sistent with either condition. There is nothing about the 
physical signs which is of any value in differential diagnosis. 
A leucocyte count would probably be of considerable assist- 
ance in diagnosis because there is almost never a leucocytosis 
with a primary serous effusion, and almost always a marked 
leucocytosis when the fluid is purulent. The absence of 
leucocytosis in primary serous effusions is presumably due to 
the fact that they are almost invariably tubercular. The only 
positive method of diagnosis is exploratory puncture. It is 
reasonably safe to make a diagnosis of Serous Pleurisy in 
this instance, however, on the history. 

A skin tuberculin test will aid much in determining whether 
or not the effusion is or is not tubercular. A more certain 



1 86 CASE HISTORIES IN PEDIATRICS. 

method, however, is by the examination of the fluid obtained 
by exploration or aspiration. There are, as a rule, a large 
excess of lymphocytes in the tubercular cases, and of poly- 
nuclear cells in the acute infectious variety. If the fluid is 
digested before the examination (inoscopy), tubercle bacilli 
can be found in a large proportion of the tubercular cases; 
in fact, more positive results are obtained in this way than 
by animal inoculations. 

An exploratory puncture was done and a serous fluid, which 
contained an excess of lymphocytes and a few tubercle bacilli, 
was obtained. 

Prognosis. There is no danger to life from the effusion if 
it is not allowed to accumulate enough to cause symptoms of 
pressure. It is not an especially serious form of tuberculosis. 
The prognosis is, therefore, that of tuberculosis in general. 

Treatment. The effusion is not causing any symptoms from 
pressure on other organs. It is, therefore, wiser not to with- 
draw it at present. Applications to the chest wall are useless. 
It is unreasonable to expect that diuretics and cathartics will 
draw the fluid from the pleural cavity, in which the pleura is 
inflamed and not in a condition to absorb fluid, rather than 
from the tissues. They cannot be of use, anyway, unless 
liquids are excluded from the diet. It is very unwise to cut 
liquids out of a child's diet, and, moreover, free catharsis is 
very weakening. They cannot, therefore, do much, if any, 
good, and are almost certain to do harm by interfering with 
the ingestion of food and weakening the patient. They 
ought not to be used in this instance. If the fluid increases 
enough to cause symptoms of pressure, or if it does not begin 
to diminish after ten days or two weeks, it should be with- 
drawn. If the chest refills, the aspiration may have to be 
repeated several times. 

He must be kept quiet in bed and well fed. The further 
treatment is that of tuberculosis in general. 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA. 1 87 

CASE 61. Sophy L. was seen in consultation when four 
and one-half years old. She had always been delicate. Seven 
and one-half weeks previously she was taken suddenly ill 
with a pneumonia involving the whole left lower lobe. She 
was under the care of Dr. G. for a week. The crisis did not 
occur during this time. Dr. G. was then discharged and 
another doctor called in. The crisis is said to have occurred 
on the eighth or ninth day. A week later Dr. G. was again 
given charge of the case. He found the temperature running 
between 103 F. and 104 F. It dropped a little after a few 
days and since then had ranged between 101 F. and 102 F. 
She had had no chills, but had sweat freely, especially about 
the head. She was not short of breath and did not complain 
of pain. She coughed occasionally. Her appetite was good, 
but she was somewhat constipated. She had lost weight 
steadily. She had been up and about the house for ten days. 
An examination of the sputum for tubercle bacilli had been 
negative. 

Physical Examination. She was slight, thin and somewhat 
pale. There was no cyanosis. She cried loudly without 
distress. The cardiac impulse was palpable just to the left 
of the sternum. The impulse was also palpable to the right 
of the sternum and was stronger there than on the left. The 
cardiac dullness extended from 2 cm. inside the right nipple 
to 1 cm. to the left of the left border of the sternum. The 
heart sounds were louder to the right than to the left of the 
sternum. The sounds were not abnormal. The left side of 
the thorax appeared larger, than the right, and moved much 
less than the right in respiration. The left intercostal spaces 
were nearly obliterated. There was flatness in the left chest 
above the third rib in front, the fifth in the axilla and the mid- 
scapula behind. In this area respiration was bronchial, and 
the voice sounds and fremitus slightly increased. Below the 
flat area down to the fifth space in front, the sixth space in 
the axilla and in the whole back there was flat tympany. 
Below this there was loud tympany. In these areas respira- 
tion was diminished, but almost vesicular in character. The 
voice sounds were diminished, but not changed in character. 
The vocal fremitus was absent. There was tympany in 



1 88 CASE HISTORIES IN PEDIATRICS. 

Traube's space. There was a very marked sense of resistance 
over the whole left chest, more marked in the lower portion 
than in the upper. The right chest was somewhat hyper- 
resonant, except that there was a triangular area of dullness 
in the back, the apex being at the level of the spine of the 
scapula, the side along the back bone and the base along the 
tenth rib, extending outward about two inches. The respira- 
tion was of normal character, but louder than normal over 
the whole right side. The upper border of the liver flatness 
was at the upper border of the sixth rib; the lower border 
was palpable 4 cm. below the costal border in the nipple line. 
The spleen was not palpable. The abdomen was rather full, 
but not tense or tender. The extremities showed nothing 
abnormal. There was no general enlargement of the super- 
ficial lymph nodes. The rectal temperature was ioo° F., the 
pulse 120, the respiration 35. 

Diagnosis. The history is so characteristic of an empyema 
secondary to pneumonia that it hardly seems necessary to 
consider anything else, unless the physical examination proves 
this supposition to be wrong. Other remote possibilities are 
an unresolved pneumonia, an acute tubercular pneumonia 
which has changed to a chronic condition, and a secondary 
tubercular infection consecutive to a pneumococcus pneu- 
monia. 

The physical signs are, however, confusing. The marked 
displacement of the heart to the right, the enlargement of 
the left chest, the obliteration of the left intercostal spaces, 
and the triangular area of dullness in the right back (Grocco's 
sign) prove that there is something in the left pleural cavity. 
The tympany in the lower portion suggests that this may be 
air. The marked sense of resistance proves that it is fluid. 
It would be almost unheard of, moreover, to have fluid or 
solid lung in the upper part of the chest and air alone in the 
lower. The tympanitic sound is undoubtedly transmitted 
from the abdomen, and the vesicular respiration and normal 
voice sounds from the right side. The bronchial respiration 
and increased voice sounds and fremitus in the upper portion 
suggest strongly that the upper half of the chest is filled by 
solid lung. The marked sense of resistance and the marked 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA. 1 89 

displacement of the heart, together with the well-known fact 
that in children the respiration and voice sounds, and some- 
times even the fremitus, may be transmitted through fluid if 
the tension is high enough, show conclusively that the upper 
as well as the lower portion of the chest is filled with fluid. 
The bronchial character of the respiration is due to the com- 
pression of the lung, which is presumably squeezed into a 
small mass at the root. The tympany in Traube's space is 
probably also transmitted from the abdomen and does not 
mean that the diaphragm is in its normal position. 

The signs in the right chest are characteristic of a compen- 
satory emphysema. The upper border of the liver flatness is 
slightly lower than normal, but not as much so as the lower 
border. This shows that the liver is enlarged. The enlarge- 
ment is probably due to fatty change, resulting from mal- 
nutrition and toxic absorption, although it may possibly be 
amyloid. 

There is undoubtedly fluid in the left pleural cavity. This 
fluid accumulated after pneumonia, and the patient is a child. 
The chances are, therefore, at least nineteen out of twenty 
that it is purulent rather than serous. The absence of chills 
does not count against, nor the presence of sweating for, a 
purulent effusion, because chills are rather unusual with an 
empyema at this age, and sweating is common in all conditions 
of weakness. The diagnosis of Purulent Pleurisy is, there- 
fore, justified without an exploratory puncture. 

Prognosis. If the chest is not opened she will almost cer- 
tainly fail steadily and finally die. There is, however, a small 
chance that the pus may eventually find a way out for itself 
or become encapsulated and absorbed. In either case, she 
is certain to be left with a very greatly deformed chest. If 
the chest is opened at once she will almost certainly recover, 
because her general condition is surprisingly good under the 
circumstances and the evidences of septic absorption com- 
paratively slight. It is six weeks since the appearance of the 
effusion, it is very large, the lung is much compressed and 
probably more or less bound down by adhesions. The 
chances are, therefore, that it will not fully expand and that 
she will be left with some deformity. 



190 CASE HISTORIES IN PEDIATRICS. 

Treatment. The only rational treatment in this instance 
is the opening and draining of the pleural cavity. It is true 
that in rare instances recovery ensues in pneumococcus 
empyema after tapping. This happens so seldom, however, 
that it cannot be regarded as a justifiable procedure. The 
almost invariable result is that the pus reaccumulates and 
that the chest has to be finally opened. In the meantime the 
general condition has been further impaired as the result of 
the continued septic absorption, and the lung has been further 
compressed and its complete expansion rendered more diffi- 
cult. The long duration and the large amount of the effusion 
in this instance make the chances of cure from aspiration 
even less than the average. She should, therefore, be operated 
on at once. The author believes that resection of a rib gives 
much better results than simple incision. A resection should 
certainly be done in this instance because, on account of the 
duration of the process, there are probably large clots and 
masses of caseous material which could not be satisfactorily 
cleaned out through an incision. 



SECTION VII. 

DISEASES OF THE HEART AND PERICARDIUM. 

CASE 62. Dillaway F., the second child of healthy par- 
ents, was delivered by version at full term, was apparently 
normal at birth and weighed seven and one-half pounds. He 
was very badly fed during his first year and suffered from 
indigestion during his second year. A murmur was discovered 
in his heart during a routine examination when he was ten 
months old. When he w T as two years old he had influenza, 
followed by pneumonia. Since then he had been well, except 
for symptoms of adenoids and occasional nosebleeds, which 
were probably due to them, until the last few months, during 
which he had had a recurrence of his indigestion. He was 
seen when four years old. He had never been short of breath 
or cyanotic. 

Physical Examination. He was fairly developed and nour- 
ished and looked well. His color was good, but when he 
cried there was, perhaps, a slight tinge of cyanosis in the 
cheeks. His throat was normal, his tongue moderately coated. 
There was no deformity of the chest. The cardiac impulse 
was visible and palpable in the fifth space in the nipple line, 
6f cm. to the left of the median line (normal is in fourth space, 
6 cm. to left of median line). The left border of the relative 
cardiac dullness corresponded to the impulse. The upper 
border of the relative dullness was at the upper border of the 
second rib (normal is in the second space), and the right bor- 
der 3 cm. to the right of the median line (normal is 2 J cm.). 
There was no dullness under the manubrium. The action 
was regular; the rate, 90 (normal). A very distinct thrill was 
felt in the second left interspace. It was also palpable, but 
much less distinctly, over the rest of the precordia. The 
first sound was everywhere distinct, but was followed over 
the whole precordia by a loud, rough murmur, loudest in the 
second left interspace. This murmur was also audible in the 

191 



I9 2 CASE HISTORIES IN PEDIATRICS. 

neck and over the whole chest, back and front. The second 
pulmonic sound was much louder than the second aortic, so 
much louder that it was undoubtedly accentuated. The 
lungs and abdomen were normal. The liver and spleen were 
not palpable. The extremities were normal. There was no 
clubbing of the fingers or toes. There was no spasm or pa- 
ralysis. The knee-jerks were equal and normal. There was 
no enlargement of the peripheral lymph nodes. 

Diagnosis. This boy undoubtedly has a cardiac lesion. 
The first thing to be decided is whether it is congenital or 
acquired; next, to determine, if possible, what the lesion is. 
The points in favor of a congenital lesion in this instance are 
the fact that the murmur was discovered when he was only 
ten months old, before he had had any disease likely to be 
accompanied by endocarditis; the slight enlargement of the 
heart in comparison with the intensity of the murmur; and 
the location of the greatest intensity of the murmur and of the 
thrill and their distribution, which do not correspond to those 
of any of the acquired lesions. The points against a congenital 
lesion are the absence of bulging of the precordia and of all 
the usual signs of interference with the oxygenation of the 
blood. There is, however, no reason for bulging of the pre- 
cordia when the heart is no more enlarged than in this 
instance, and it is perfectly possible to have congenital lesions 
which from their nature, or from the presence of compensa- 
tory lesions, do not interfere with the oxygenation of the 
blood. A positive diagnosis of Congenital Heart Disease 
is, therefore, justified. 

It is impossible during life to make a certain diagnosis of 
the exact lesion in congenital heart disease, although a prob- 
able diagnosis is often possible. In this instance the location 
of the maximum intensity of the murmur and of the thrill in 
the second left interspace and the transmission of the murmur 
into the neck point strongly to a narrowing of the pulmonic 
orifice. The absence of all signs of deficient oxygenation of 
the blood shows that there must be some compensatory lesion. 
The accentuation of the second pulmonic sound suggests that 
this lesion is an open ductus arteriosus. 

Prognosis. He has reached the age of four years and has 



DISEASES OF THE HEART AND PERICARDIUM. I93 

passed through a pneumonia without the appearance of any 
symptoms referable to the heart, has perfect compensation 
with but little cardiac enlargement, and has developed nor- 
mally. It seems reasonable to suppose, therefore, that his 
cardiac lesion will not interfere with his growth and develop- 
ment and that he will reach adult life and perhaps attain old 
age. The prognosis in this instance is as good, if not better, 
than it would be if he had an acquired lesion. 

Treatment. He requires no treatment at present, except 
that it will be advisable for him to avoid continued, excessive 
exertion. If failure of compensation develops, the treatment 
will be that of failure of compensation in general. 



194 CASE HISTORIES IN PEDIATRICS. 

CASE 63. William C.'s father had died of tuberculosis 
just before he was born. He had had no known exposure to 
tuberculosis. He had been unusually rugged until he was 
eight years old, when he had otitis media followed by inflam- 
mation of the mastoid and operation. A considerable amount 
of adenoids was removed at the same time. He was kept out 
of school for a year, but did not regain his strength. He was 
easily tired and not nearly as vigorous as before. An enlarge- 
ment of several of the cervical lymph nodes, which had de- 
veloped at the time of the mastoid operation, persisted until 
his tonsils were removed, when he was ten and one-half years 
old, since when they had become much smaller. He had 
chicken-pox when eleven and one-half years old and was 
considerably pulled down by it. Since then he had been 
generally below par and very easily tired. His appetite had 
been poor, but he had shown no signs of indigestion. His 
bowels had moved regularly, and the movements had been 
normal. He had had no cough. He complained a little of 
shortness of breath on exertion, but never of palpitation. 
Once, after unusual exertion, and at another time after 
getting tired, he had run a temperature between 99° F. and 
100 F. for several days. At other times his temperature had 
been normal. He had been kept very quiet during the last 
few months and not allowed to take any active exercise. He 
went to bed early and usually slept about eleven hours, but 
had no rest during the day. He had grown tall very rapidly 
during the last six months. He was of a very nervous type 
and was much worried about himself. He had no bad habits. 
He was seen when eleven and three-fourths years old. 

Physical Examination. He was tall and rather slight, but 
of fair color. His throat and mouth were healthy and his 
tongue nearly clean. There was no venous hum in the neck. 
The cardiac impulse was palpable in the fourth left space, 
7 1 cm. to the left of the median line. The left border of the 
relative cardiac dullness was 7§ cm. to the left, and the right 
border 3 cm. to the right of the median line; the upper border 
was at the upper border of the third rib. That is, taking his 
height into consideration, the measurements to the left were 
a little small, while the others were normal. The cardiac 



DISEASES OF THE HEART AND PERICARDIUM. 1 95 

action was somewhat irregular in rhythm; the rate, 88. 
The cardiac action was steadied by exertion. The first sound 
was everywhere of fair strength. It was at times followed, 
both at the pulmonic and mitral areas, by short murmurs 
which were not transmitted. The second pulmonic sound was 
not accentuated. The lungs and abdomen were normal. 
The liver and spleen were not palpable. The extremities 
were normal. There was no spasm or paralysis. The knee- 
jerks were equal and lively. Kernig's sign was absent. 
Numerous lymph nodes, varying in size from that of a pea to 
that of a large bean, were palpable in the neck. There was 
no enlargement of the axillary and inguinal and no evidence 
of enlargement of the bronchial lymph nodes. His weight 
was eighty-nine and one-fourth pounds (average, seventy- 
six and one-half pounds). His height was fifty-nine and 
three-fourths inches (average, fifty-five). 

The urine was clear, highly acid in reaction, of a specific 
gravity of 1,038 and contained no albumin or sugar. 

Blood. 

Hemoglobin, 90% 

Red corpuscles, 4,500,000 

White corpuscles, 7,200 

Smears of the blood showed nothing abnormal in either the 
red or the white corpuscles. 

Diagnosis. The enlargement of the cervical lymph nodes 
is in all probability not tubercular, because it came on in the 
course of an acute disease, has never shown any tendency to 
suppurate and has diminished in size since the tonsils were 
removed. The fact that his father died of tuberculosis is of 
no importance, because he was not exposed to tuberculosis 
from him. There are no evidences of tuberculosis elsewhere. 
It is reasonably safe to conclude, therefore, that his poor 
condition is not due to tuberculosis. 

The point of chief interest is the condition of the heart. 
It is certainly not an acute one. Is the trouble organic or 
functional? Anemic murmurs do not have to be considered 
because of the condition of his blood and the absence of a 
venous hum in the neck. The absence of enlargement of the 



I96 CASE HISTORIES IN PEDIATRICS. 

heart, taken in combination with the strong first sound and 
the absence of accentuation of the second pulmonic sound, 
show that there is no dilatation or hypertrophy of the heart, 
which would certainly be present if there was any chronic 
leakage at the mitral orifice. The presence of a murmur at 
the pulmonic orifice and the absence of transmission of the 
murmurs is also against an organic lesion. The steadying of 
the heart on exertion, the rapid growth, the nervous tempera- 
ment, the history of the previous illnesses and the fact that 
he is about the age of puberty, all point to a functional condi- 
tion. It is safe to conclude, therefore, that the Cardiac 
condition is Functional, not organic. 

Prognosis. The prognosis is perfectly good with time. It 
will probably be several years before he will be strong and 
vigorous. The irregularity of the heart and the murmurs will 
probably disappear much sooner. 

Treatment. The treatment must be by regulation of his 
daily life, not by drugs. In the first place, he must be assured 
that there is nothing serious the matter with him, that his 
weakness is merely the result of his illness and his rapid growth 
and that he will surely be all right again. He must not go to 
school more than half a day. If he does not go at all, he will 
have too much time to think about himself. He must be 
amused in quiet ways. He must partly undress and lie down 
for an hour at noon and rest, even if he does not sleep. He 
must be in bed at eight. It will be a good thing for him to 
sleep out of doors. He can walk, drive, ride in an automobile, 
play golf and work a little about the house, but must not 
play baseball or football, ride a bicycle or skate. He may 
have any reasonable food. He should have three good meals 
and a lunch in the morning. Care must be taken that his 
bowels move regularly. Tincture of nux vomica, in eight- 
drop doses, three times daily, before meals, will probably 
improve his appetite and his general condition. 



DISEASES OF THE HEART AND PERICARDIUM. 



197 



CASE 64. Ernest M., nine years old, was admitted to the 
Children's Hospital January 5, on the sixth day of a pneu- 
monia of the left lower lobe. He was in good condition and the 
physical examination showed nothing else abnormal. The 



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Fig. 6. Ernest M. Case 64. 

cardiac impulse was visible and palpable in the fifth space, 
7 cm. to the left of the median line and just inside the nipple 
line. The upper border of the relative cardiac dullness was 
at the upper border of the third rib; the left border corre- 



I98 CASE HISTORIES IN PEDIATRICS. 

sponded to the impulse and the right border was 2\ cm. to the 
right of the median line (all normal). The action was regular. 
The first sound was of fair quality. The second sounds were 
alike. There were no murmurs. 

The crisis, as will be seen by the chart, occupied two days. 
The temperature reached normal the afternoon of January 7. 
The pulse remained good during the crisis. The temperature 
remained down and the lung began to clear at once, but the 
pulse became infrequent and irregular the night of the 8th. 
The examination the next morning, January 9, was as follows: 

Physical Examination. He was perfectly comfortable and 
of good color. The cardiac impulse was wavy and visible in 
several spaces. It was most distinctly palpable in the fifth 
space, 8| cm. to the left of the median line. The upper 
border of the relative cardiac dullness was in the second space, 
the left border was just outside the point of maximum im- 
pulse and the right was 4 cm. to the right of the median line. 
The action was irregular in both force and rhythm; the rate 
was 68 (normal is 80 to 90). All the beats were transmitted 
to the wrist. The first sound was everywhere short and some- 
what feeble. The second sounds were alike. There were no 
murmurs. There was still a little dullness and a few moist 
rales over the left lower lobe. The physical examination 
showed nothing else abnormal. 

Diagnosis. The physical signs are those of weakness and 
dilatation of the heart. The weakness and dilatation cannot 
be the results of an endocarditis, because the heart was 
normal four days before and no leakage which did not show 
then could possibly have caused so much dilatation and weak- 
ness in four days. There is no cause outside of the heart to 
account for its sudden failure. The cause of the dilatation and 
weakness must, therefore, be in the heart wall. That is, there 
is a Myocarditis. The diminution of the second sound at 
the pulmonic area at entrance (the second pulmonic sound is 
normally louder than the second aortic at this age) showed 
that the right ventricle was unable to meet the increased 
resistance in the pulmonary circulation and gave warning of 
what happened later. 

Prognosis. The prognosis is a grave one. A marked 



DISEASES OF THE HEART AND PERICARDIUM. 1 99 

diminution in the pulse-rate in myocarditis is as serious, if 
not more so, than a marked increase in the rate. He may die 
at any time; he may slowly improve and finally recover 
entirely. It is impossible to forecast what will happen. The 
outlook depends to a considerable extent on the treatment. 

Treatment. The most important part of his treatment is 
quiet. He must be kept perfectly flat and not allowed to sit 
up for any reason whatever. He must be kept flat, or nearly 
flat, until the cardiac action and rate are normal and all signs 
of dilatation and weakness have disappeared. He may then 
begin to gradually get up and about. Alcohol is useless in 
myocarditis, except as a food. In large doses it undoubtedly 
does harm. Strychnia may possibly help some. Digitalis 
cannot act on a degenerated muscle. Nitroglycerin is danger- 
ous because it predisposes to vasomotor paralysis. There is, 
therefore, no drug treatment indicated at present. He may 
have liquids in moderate amounts, soft solids and eggs. It 
will be wiser to give him small meals five or six times in the 
twenty-four hours than large ones at longer intervals. 



200 CASE HISTORIES IN PEDIATRICS. 

CASE 65. Samuel C, four and one-half years old, had 
been perfectly well since an attack of acute nephritis two 
years before. About two weeks before he was seen he began 
to complain of pain and stiffness in the ankles, wrists and 
elbows. He apparently did not feel sick and was not feverish. 
He had been allowed to be out of doors as usual, although it 
was winter. He had had no treatment. The day he was seen 
he had not seemed quite as well, although nothing very definite 
had appeared. He was seen in the evening. 

Physical Examination. He was well developed and nour- 
ished and of good color. He did not seem sick. He com- 
plained of slight pain when his ankles, wrists and elbows were 
moved. The right wrist was tender on pressure; the other 
joints were not. There was no redness, heat or swelling about 
any of them. The cardiac impulse was visible and palpable 
in the fifth space, 8 cm. to the left of the median line (the 
normal is in the fourth space, 6 to 6| cm. to the left of the 
median line). The upper border of the relative cardiac 
dullness was at the lower border of the second rib (normal 
is in second space), the right border 2§ cm. to the right of the 
median line (normal), and the left border 8 cm. to the left of 
the median line (normal is 6 to 6| cm.). The cardiac action 
was somewhat irregular; the rate was 104 (normal is 90 to 
100). The first sound at the apex was strong, but continued 
into a short, blowing murmur, transmitted into the axilla. 
The second sound at the apex was reduplicated. The second 
sound at the pulmonic area was accentuated. The lungs and 
abdomen were normal. The liver and spleen were normal. 
There was no spasm or paralysis. The knee-jerks were equal 
and normal. There was no enlargement of the peripheral 
lymph nodes. There was no venous hum in the neck. The 
mouth temperature was 102 F. 

Diagnosis. The history and the conditions found in the 
joints are typical of Rheumatism in childhood, at which age 
marked joint and constitutional symptoms are very un- 
common. The disease is, therefore, very often overlooked, 
as it was in this instance. Unfortunately the heart is involved 
even more frequently in this mild type of rheumatism in 
childhood than it is in the severe type in adult life. 



DISEASES OF THE HEART AND PERICARDIUM. 201 

There is undoubtedly something abnormal about the heart. 
The possibilities are acute endocarditis, myocarditis and an 
anemic murmur. The latter can be at once excluded on the 
good color, the absence of a venous hum in the neck and the 
enlargement of the heart. The absence of a murmur at the 
pulmonic area is also against it. Myocarditis can be ruled out 
on the character of the impulse, the strength of the first sound 
and the accentuation of the second sound in the pulmonic 
area. The absence of enlargement to the right and of much 
increase in the rate of the pulse is also against it. The diag- 
nosis is, therefore, by elimination, Acute Endocarditis of 
the mitral valve. The combination of a systolic. murmur at 
the apex with a strong impulse, strong first sound, but little 
increase in the rate of the heart, enlargement limited to the 
left side and an accentuation of the second pulmonic sound, is, 
moreover, characteristic of an early endocarditis of the mitral 
valve. 

Prognosis. There is no immediate danger to life from the 
endocarditis, the chief immediate danger being the simul- 
taneous involvement of the myocardium and pericardium. 
When all parts of the heart are involved, the prognosis is 
always a grave one. There is, however, very little chance of 
complete recovery. The disease is almost certain to result 
in permanent deformity of the mitral orifice. There is, more- 
over, great danger of recurrence of the rheumatism in the 
future with further damage to the endocardium. It must be 
remembered in this connection that the murmurs due to 
acute endocarditis frequently disappear, to be followed later 
by those due to cicatricial changes in the orifices. The dis- 
appearance of the murmur does not, therefore, justify a 
favorable prognosis. This can only be given when the mur- 
mur has not reappeared after an interval of one or two years. 

Treatment. The author is one of those who believe that 
the salicylates do good in rheumatism. It seems reasonable 
that, if they help rheumatism, they will have a favorable 
influence upon the endocarditis, which is a manifestation of 
rheumatism. It is hard to understand, at any rate, how they 
can do any harm in rheumatism, as some writers claim they 
do. The most satisfactory preparation of salicylic acid for 



202 CASE HISTORIES IN PEDIATRICS. 

children is aspirin. This boy should have five grains every 
three hours until the joint symptoms and fever are relieved, 
unless he gets toxic symptoms. If he does, the dose should be 
reduced. It should be continued in the same dose, three 
times a day, for several days or a week longer. 

The most important thing in the treatment of acute endo- 
carditis in childhood is rest. Everything else is subordinate. 
He must be kept in bed not only during the acute stage, but 
for months longer. Three months is the minimum. A week 
in bed at this time may mean a year of life later. In the 
beginning he must be kept flat or as nearly flat as is possible. 
Judgment must be used in this connection, however, because 
he may fret and fuss so much at being kept flat that he will 
bring more strain on his heart than if he is allowed to sit up. 
His life must be most carefully regulated for a year or two 
after he gets up, and the amount of exertion limited. He will 
feel perfectly well and will wish to do what other children do. 
He must, however, be restrained. His whole life must be 
planned so as to save the heart. 

His compensation is perfectly good. There is, therefore, 
no call for either cardiac stimulants or tonics. If he is restless 
or uncomfortable, he may be given the bromide of sodium or 
potassium in five- or ten-grain doses, or morphia in doses of 
from one thirty-second to one sixteenth of a grain. 

There are no special indications as to his diet. He must be 
given a milk and starchy diet at first. Later, there is no 
objection to meat and eggs. Special attention must be paid 
to his nutrition, as the condition of the heart muscle depends 
to a considerable extent on the general nutrition. 



DISEASES OF THE HEART AND PERICARDIUM. 203 

CASE 66. Levi P., fifteen years old, had had repeated 
attacks of rheumatic fever since he was four years old. He 
began to be short of breath on exertion when he was fourteen, 
but this was never severe enough to cause any inconvenience. 
He occasionally suffered from palpitation. He had another 
attack of rheumatic fever the latter part of May. Since then 
dyspnea and palpitation had been very troublesome and any 
exertion completely exhausted him. His appetite was good 
and his bowels moved regularly. He had no signs of indiges- 
tion. He had a slight cough, but no expectoration. The 
dyspnea and palpitation finally became so troublesome that 
he gave up and went to bed June 16. He was able to lie 
down, but was more comfortable sitting up. Rest in bed 
made him more comfortable until June 20, when he began to 
complain of pain and oppression in the chest. He became 
rapidly worse, so that on the 22d he was unable to lie down 
with comfort, was restless and had begun to vomit. The 
temperature, which had been running between normal and 
101 F., gradually went up to 102 F., and the rate of the 
pulse and respiration rose from 100 and 25 to 140 and 40, 
respectively. He was seen in consultation June 22. 

Physical Examination. He was well developed^and nour- 
ished. He was restless and unable to lie down. His expres- 
sion was anxious. He was everywhere slightly cyanotic. 
The cardiac impulse was not visible; it was palpable in the 
fourth space, midway between the sternum and the nipple 
(normal is fifth space, 1 cm. inside the nipple). The upper 
border of the relative cardiac dullness was at the upper border 
of the second rib (normal is middle of third rib) ; the left 
border 13 cm. (normal is 8 or 9 cm.) to the left of the median 
line; the right border 6 cm. (normal is 3 to 4 cm.) to the right 
of the median line in the fourth space, and 7 cm. to the right 
of the median line in the fifth space. The action was regular; 
the rate, 140. The heart sounds were markedly feeble. The 
first sound at the apex was preceded by a faint, rumbling sound 
and directly followed by a soft, blowing sound which was 
transmitted toward the axilla. The second pulmonic sound 
was somewhat louder than the second aortic. There was a 
soft, double, rubbing sound close to the ear and increased by 



204 CASE HISTORIES IN PEDIATRICS. 

pressure of the stethoscope, synchronous with the heart beat, 
under the manubrium and in the second spaces. The pulse 
was fairly strong. There was an area of dullness, with bron- 
chovesicular respiration and slightly increased voice sounds, 
at the base of the left lung, extending outward about 7 cm. 
from the median line and upward about 5 cm. There were 
numerous very fine, moist rales in both lower backs. The 
lungs were otherwise normal. The upper border of the liver 
flatness was at the upper border of the sixth rib in the nipple 
line; the lower border was not palpable. The spleen was not 
palpable. The abdomen was normal. The extremities showed 
nothing abnormal. There was no spasm or paralysis and no 
edema. 

The urine was high, acid in reaction, of a specific gravity of 
1,024 an d contained neither albumin nor sugar. The sedi- 
ment showed nothing abnormal. 

Diagnosis. The trouble is, of course, entirely cardiac. 
The condition in the heart is, however, a fairly complicated 
one. The location of the impulse well inside the left border 
of the cardiac dullness, the combination of feeble heart sounds 
with a regular action, a reasonably strong pulse, and an accen- 
tuated second pulmonic sound, and the extension of the 
right border of dullness farther to the right in the fifth than 
in the fourth space (thus making the cardio-hepatic angle 
obtuse) prove that there is a Pericardial Effusion. The 
peculiar characteristics of the double rubbing sound under 
the manubrium and in the second spaces show that there is 
also a Dry Pericarditis at the base. This is corroborative 
evidence of pericardial effusion. The presence of cyanosis 
and distress without edema and enlargement of the liver and 
spleen also counts in favor of a pericardial effusion and against 
a dilatation of the heart. The effusion developed immedi- 
ately after an attack of rheumatism, and is, therefore, almost 
certainly serous. The absence of marked irregularity in the 
temperature and of chills and sweating is also in favor of a 
serous fluid. 

The double murmur at the apex shows that there is a lesion 
at the Mitral orifice, certainly Insufficiency, probably 
Stenosis, perhaps only roughening of the orifice. The 



DISEASES OF THE HEART AND PERICARDIUM. 205 

effusion into the pericardium makes it impossible to determine 
the size of the heart. The accentuation of the second pul- 
monic sound shows, however, that there must be hypertrophy 
of the heart and that, if there are both dilatation and hyper- 
trophy, the hypertrophy is in the ascendance. The history of 
repeated attacks of rheumatism and of dyspnea and palpita- 
tion before the present illness shows that the lesion is a chronic 
one. The accentuation of the second pulmonic sound is 
corroborative evidence. The strength of the pulse, the good 
second sound and the regularity of the heart show that the 
myocardium is but little, if at all, affected. 

The area of dullness and bronchovesicular respiration in 
the lower left back is due to compression of the lung by the 
pericardial effusion. The rales show a small amount of edema 
of the lungs. 

Prognosis. The prognosis in this instance, as always in 
pericarditis with effusion, especially if associated with chronic 
valvular lesions, is a very grave one. The most favorable 
point here is the absence of myocardial involvement. There 
is a reasonable chance, perhaps one in four, that he will sur- 
vive the present acute condition. He will be left, however, 
not only with a chronic valvular lesion, but also with an ad- 
herent pericardium. He is also very liable to have more 
attacks of rheumatism and further involvement of the heart. 
If he survives the present attack, the chances are, therefore, 
that he will live but a few years. 

Treatment. The first thing to be decided is whether it is 
advisable to tap the pericardium. The heart is standing up 
to the increased work very well, as is shown by the regularity 
of its action, the good pulse and the accentuation of the second 
pulmonic sound; there is almost no edema of the lungs and 
no signs of passive congestion elsewhere. If he can be kept 
under close observation, it will be wise to delay aspiration in 
the hope that the effusfon will diminish rather than increase. 
If the heart weakens or signs of passive congestion appear, the 
pericardium must be tapped at once. Blisters and the appli- 
cation of other counterirritants to ' the precordia can do no 
good, will make him uncomfortable and increase the chances 
of septic infection. A light ice-bag, suspended over the pre- 



206 CASE HISTORIES IN PEDIATRICS. 

cordia so as not to cause pressure, may make him more com- 
fortable and in some instances seems to favor the absorption 
of the fluid. Tincture of digitalis, in doses of five drops every 
four hours, will help the heart to meet the increased work 
thrown on it by the pressure of the fluid in the pericardium. 
This dose may be doubled or trebled, if necessary. He may 
sit up or lie down, according to which is the more comfortable. 
Fresh air will make his breathing easier. Oxygen may be 
given, if necessary. There is no objection to morphine, in 
doses of from one sixteenth to one eighth of a grain, if he is 
very uncomfortable. 

He must be fed often with small amounts of liquids and soft 
solids, since swallowing is often very painful and chewing 
tiresome. 



DISEASES OF THE HEART AND PERICARDIUM. 207 

CASE 67. Clarence G., eleven years old, was the child of 
healthy parents. There was nothing in the family history to 
suggest syphilis. There was no tuberculosis in the family and 
he had had no known exposure to it. He was born at full 
term after a normal labor and was normal at birth. He was 
breast-fed and was very well as a baby. He had measles and 
whooping-cough when five, diphtheria when six, scarlet fever 
when seven, and chicken-pox when nine years old. He had a 
short indefinite illness, associated with pains in the extremi- 
ties, in January, 1907, which was called " grippe." His ab- 
domen began to swell about the first of April, 1907. Some 
months later he began to be short of breath and to have a 
little swelling of the legs. The swelling of the abdomen and 
the dyspnea did not change much, but the swelling of the 
extremities often disappeared entirely for a time. His appe- 
tite and digestion continued good. Recently he had been 
unable to lie down with comfort, had had some cough and 
more swelling of the legs. He had had no fever. He was seen 
September 9, 1908. 

Physical Examination. He was well developed and nour- 
ished and of good color, but unable to lie down without much 
discomfort. There was no edema of the face or chest, and no 
enlargement of the superficial veins of the chest. There was 
no tracheal tug and no diastolic collapse of the veins in the 
neck. The tongue was clean, the throat normal. There was 
no dullness under the manubrium. The cardiac impulse was 
not visible and was only feebly palpable in the region of the 
nipple. There was no systolic retraction either here or in the 
back. The upper border of the relative cardiac dullness was 
at the upper border of the third rib; the left, just outside the 
left nipple (normal is 1 cm. inside) ; the right, 5 cm. to 
the right of the median line (normal is 3 cm. to the right of 
the median line). The cardio-hepatic angle was acute. The 
action was regular. The first sound was a little short and 
sounded a little distant. The second pulmonic sound was not 
accentuated. There were no murmurs. There was dullness, 
changing to flatness toward the base, on the left side below 
the spine of the scapula behind, the fifth rib in the axilla and 
the third rib in front. The respiration and voice sounds in 



208 CASE HISTORIES IN PEDIATRICS. 

this area were somewhat diminished in intensity, but not 
changed in character. The vocal fremitus was somewhat 
diminished. A few rales were heard. There was dullness over 
the whole right back with a few fine, moist rales at the base. 
The abdomen was much and symmetrically enlarged. There 
was no enlargement of the superficial veins. There was 
flatness in the flanks and hypogastrium, the upper border of 
the flatness being concave when he lay on his back. The 
area of flatness changed with change of position and there 
was a definite fluid wave. No masses were felt. The upper 
border of the liver flatness was at the upper border of the 
fifth rib in the nipple line (normal is at the upper border of 
the sixth rib) ; the lower border of the liver was palpable 
ii cm. below the costal border in the nipple line (not nor- 
mally palpable). The spleen was not palpable. There was 
some edema of the external genitals and legs. The pulse was 
stronger in the left than in the right wrist, and was of the 
paradoxical type. There was no enlargement of the peripheral 
lymph nodes. 

The urine was normal in color, acid in reaction and of a 
specific gravity of 1,025. It showed a very slight trace of 
albumin, but did not contain sugar. The sediment showed an 
occasional hyaline and fine granular cast, a few free leucocytes 
and many squamous cells. 

Blood. 



Hemoglobin, 


80% 


Red corpuscles, 


5,600,000 


White corpuscles. 


6,700 


Mononuclears, 


22% 


Polynuclear neutrophiles, 


76% 


Eosinophiles, 


1% 


Myelocytes, 


1% 



There was no variation in the size or shape of the red cells 
and no stippling. 

A skin tuberculin test was negative. 

Diagnosis. The most reasonable explanation of this boy's 
condition is as follows: The illness which was called " grippe " 
was in all probability rheumatism. He developed a low-grade 
pericarditis and mediastinitis which resulted in the oblitera- 



DISEASES OF THE HEART AND PERICARDIUM. 209 

tion of the pericardial cavity and the formation of adhesions 
between the pericardium and the mediastinal tissues. The 
negative tuberculin test shows that this process was not 
tubercular, as it sometimes is. The points in favor of this 
assumption are the feeble cardiac impulse and the enlarge- 
ment of the area of dullness in connection with normal heart 
sounds, the paradoxical pulse and the difference in the strength 
of the pulse in the two wrists. Many other signs, sometimes 
present in this condition, are, it is true, lacking, but these 
seem sufficient to justify the diagnosis. 

The inflammatory process extended to the pleurae and 
resulted in the formation of pleural adhesions and thickening, 
which account for the signs in the backs. The pleural adhe- 
sions interfere with expansion of the lungs, as does the pressure 
of the distended abdomen and of the enlarged liver, and cause 
a congestion at the bases, which accounts for the rales. 

The chronic adhesive pericarditis produced a cirrhosis of 
the liver. This type of cirrhosis is a peculiar one and due only 
in part to passive congestion. It is not accompanied by the 
signs of congestion in other organs. The first symptom of 
this condition which is usually noticed is, as in this instance, 
enlargement of the abdomen as the result of ascites. The 
edema of the external genitals and legs is due to the pressure 
of the fluid in the abdomen on the inferior vena cava, not to 
passive congestion. The changes in the urine are presumably 
largely due to passive congestion of the kidneys from the 
pressure of the ascitic fluid on the renal veins and cava. 
The final diagnosis is, therefore, Chronic Adhesive Peri- 
carditis, with sequelae. 

Prognosis. There is, of course, no cure for the lesions in 
the pericardium, mediastinum, pleurae and liver. He will 
probably live, however, for a number of years. 

Treatment. Tapping the abdomen from time to time will 
make him much more comfortable. Other treatment must 
be symptomatic. 



SECTION VIII. 

DISEASES OF THE LIVER. 

CASE 68. Richard B. was weaned suddenly July i, when 
about nine months old, because his mother was found to be 
pregnant. He was very large at birth and had gained weight 
very rapidly. He was not as active, either physically or 
mentally, as most babies of his age. He was given a very 
improper diet and after a few days began to vomit and have 
loose, undigested movements. A careful physical examina- 
tion, made by a physician who saw him July II, showed the 
edge of the liver 2 cm. below the costal border in the nipple 
line. He was then cleaned out thoroughly and given only 
water. He was kept on water some days, nutrient enemata 
being given in addition. These were, however, not well re- 
tained. After about ten days he was given cereal waters, 
which he did not like and of which he took very little. He 
continued to have from three to four loose, yellow movements 
daily and, in consequence, he was given no milk until August 
1, when he was put on a mixture of one part of skimmed milk 
and three parts of arrowroot water. He took about twenty- 
four ounces of this mixture in twenty-four hours. His move- 
ments had become a little firmer since the milk was begun. 
He had been cleaned out thoroughly several times during the 
last three weeks and had had his bowels irrigated once or twice 
daily. He had been taking bismuth steadily, as well as three 
drops of whiskey every three hours. His temperature had 
varied from normal to ioo° F. He lay quietly most of the 
time and seldom cried, although he occasionally whined. 
The physician had noticed a hard swelling in the abdomen 
about ten days before. It had steadily increased in size. He 
was seen in consultation August 4. 

Physical Examination. He was still a good-sized baby, 
although he had evidently lost much weight. He was very 

211 



212 CASE HISTORIES IN PEDIATRICS. 

pale and paid very little attention to anything that was done 
to him. The anterior fontanelle was 3 cm. in diameter and 
somewhat depressed The bones of the skull did not overlap. 
There was no rigidity of the neck. There was a venous hum 
in the neck. The pupils were equal and reacted to light. 
The tongue was slightly coated ; the mouth and throat were 
normal. He had six teeth. The heart and lungs were normal. 
The upper border of the liver flatness in the nipple line was 
at the upper border of the fifth rib. The edge of the liver 
could be felt running across the abdomen just above the 
right anterior superior spine to the left costal border in the 
nipple line. The liver was hard, the surface smooth, the edge 
slightly rounded. It was slightly tender. The spleen was 
not palpable. The abdomen was otherwise normal. The 
extremities were normal except for slight edema of the feet. 
There was no spasm or paralysis. The knee-jerks were equal 
and feeble. Kernig's sign was absent. There was a fine pur- 
puric eruption on the abdomen and on the feet. There was 
no enlargement of the peripheral lymph nodes. The rectal 
temperature was 98 F. 

The urine was pale, acid in reaction, and of a specific 
gravity of 1,010. It contained neither albumin nor sugar. 

Diagnosis. The most striking thing in the physical examina- 
tion is the enlargement of the liver, which has developed in 
less than three weeks. This enlargement has come on too 
rapidly to be due to any form of cirrhosis ; it cannot be due to 
passive congestion, because the heart and lungs are normal; 
there is no cause for amyloid change; the enlargement is too 
uniform for malignant disease. The only reasonable ex- 
planation for the enlargement is fatty change. The cause of 
this fatty change is not difficult to find. He nas had practi- 
cally no nourishment for more than three weeks, and must 
also have had a certain amount of toxic absorption from the 
intestines during this time. Disturbance of nutrition is one 
of the most common causes of fatty change in the liver, and 
intestinal toxemia in infancy almost always causes fatty 
degeneration of the liver. The pathological condition in the 
liver is undoubtedly a mixture of fatty infiltration and de- 
generation, the infiltration being the more important. The 



DISEASES OF THE LIVER. 213 

hard, smooth surface and the slightly rounded edge are also 
characteristic of the fatty liver. The diagnosis of " Fatty 
Liver " is, therefore, justified. 

The pallor and the venous hum in the neck are signs of 
anemia, which is undoubtedly also due to the disturbance of 
the nutrition from the lack of food. The purpuric eruption is, 
likewise, merely a sign of disturbed nutrition. 

Prognosis. The prognosis is a serious one. It is impossible 
to determine at once whether or not the disturbance of 
nutrition has progressed so far that recovery is impossible 
when proper food is given. Time alone can settle this point. 

Treatment. The only food which is likely to be utilized in 
this instance is human milk. This should be obtained at 
any cost. If he will not nurse or take it well from the bottle, 
it must be given through a tube passed through the mouth. 
If human milk cannot be obtained, a modified milk, low in 
fat and high in sugar and proteids, will be the best substitute. 
A mixture containing 1. 00% of fat, 7.00% of sugar and 2.00% 
of proteids is a suitable one. There are no drugs that will 
help him. It is important, of course, to handle him as little 
as possible, to keep him warm and to give him a large supply 
of sunlight and fresh air. 



214 CASE HISTORIES IN PEDIATRICS. 

CASE 69. William H.'s father and mother were living and 
well, as were three other children, one older and two younger 
than the patient. There had been no deaths in the family, 
but his mother had miscarried after her first child was born. 
He had had no known exposure to tuberculosis. He was born 
at full term and had always been well except for an attack of 
bronchopneumonia when he was a month old, and measles 
and mumps when he was three years old. His digestion 
had always been good. No history of alcoholism could be 
obtained. 

He had been running down since the early spring, but was 
still able to be up and about most of the time. He was often 
drowsy and frequently complained of headache. He had been 
more or less jaundiced since May. The skin was nearly clear 
at times, but the eyes were always yellow. His appetite was 
good and he did not vomit or complain of pain in the abdomen. 
The bowels moved daily; the movements were rather light in 
color, but never gray or white. The urine was often dark 
colored and had recently stained his clothing yellow. He was 
seen September 26, when six years old. 

Physical Examination. He was well-developed and fairly 
nourished. The skin, conjunctivae and mucous membranes 
were distinctly yellow. His tongue was clean; his teeth in 
fair condition. The throat was normal. The cardiac impulse 
was palpable in the fourth space in the nipple line, 6 cm. to 
the left of the median line. The upper border of the relative 
cardiac dullness was at the upper border of the third rib, the 
right border 2\ cm. to the right of the median line. The 
action was regular. The first sound was of fair strength, but 
was followed at the apex and pulmonic area by very faint 
murmurs, which were not transmitted. The second pulmonic 
sound was not accentuated. There was a venous hum in the 
neck. The lungs were normal. The upper border of the liver 
flatness was in the fifth space ; the lower border was palpable 
4 cm. below the costal border in the nipple line. The edge was 
somewhat rounded, the surface smooth. The gall bladder 
was not palpable, no masses could be made out, and the liver 
was not tender. The spleen was not palpable and was not 
enlarged to percussion. The abdomen was moderately dis- 



DISEASES OF THE LIVER. 215 

tended and the superficial veins in the upper portion enlarged. 
There was slight dullness in the flanks, but it did not change 
with change of position, and there was no fluid wave. The 
extremities were normal. There was no spasm or paralysis. 
The knee-jerks were equal and normal. There was no edema 
of the extremities. There was no enlargement of the periph- 
eral lymph nodes. There was no eruption and no scars of old 
eruptions. There were no mucous patches or rhagades. The 
rectal temperature was normal. 

The urine was dark in color, acid in reaction, of a specific 
gravity of 1,030, and contained the slightest possible trace 
of albumin and much bile, but no sugar. The sediment 
showed many small round cells, a few red blood corpuscles, 
leucocytes and squamous cells, and an occasional hyaline and 
fine granular cast. 

The stools were loose, brownish and foul, and were shown by 
chemical examination to contain bile pigment. 

The leucocyte count was 9,900. 

A skin tuberculin test was negative. 

Diagnosis. Syphilis of the liver can be ruled out on the good 
family history and the absence of all other signs of syphilis. 
Less important points against syphilis of the liver are the 
presence of jaundice and the absence of enlargement of the 
spleen. Tuberculosis of the liver can be excluded on the nega- 
tive tuberculin test. The facts that there are two murmurs, 
that they are not transmitted, that the second pulmonic 
sound is not increased, that the heart is not enlarged and that 
there is a venous hum in the neck show that the murmurs in 
the heart are anemic. The heart being otherwise normal, 
cirrhosis of the liver secondary to chronic adhesive peri- 
carditis can be eliminated. The presence of bile in the stools 
rules out duodenal indigestion and obstruction of the large 
bile ducts. Abscess of the liver can be excluded on the 
absence of fever and the low white count. The marked jaun- 
dice and the beginning ascites are also against it. The smooth 
surface of the liver and the presence of jaundice without 
obstruction of the large ducts makes a new growth extremely 
improbable. The diagnosis is, therefore, by exclusion, 
Cirrhosis of the Liver. The absence of enlargement of the 



2l6 CASE HISTORIES IN PEDIATRICS. 

spleen, which is one of the earliest signs of hypertrophic 
cirrhosis, and without which this diagnosis is not justified, 
makes cirrhosis of the atrophic variety, in the pre-atrophic 
stage, the most probable diagnosis. There is nothing in the 
history to account for the development of the cirrhosis, since 
chronic alcoholism and disease of the gastro-enteric tract can 
be excluded. 

Prognosis. There is no chance for recovery. He will 
probably not live many months. 

Treatment. The treatment can be only symptomatic. 



DISEASES OF THE LIVER. 217 

CASE 70. Richard D. was seen in consultation when six 
years old. His mother had had a cancer of the breast removed 
eight years before. She was well for six years, when she had 
a recurrence in the liver and glands, and died a year later. 
He had always been well before the present illness. 

He had not been up to mark since an attack of chicken-pox 
several weeks before he was seen. There had, however, been 
no definite symptoms. Enlargement of the abdomen and of 
the superficial lymph nodes was first noticed a week before. 
The abdomen had increased in size very rapidly during the 
week. His appetite had fallen off, but there had been no 
nausea, vomiting or pain in the abdomen. The bowels had 
moved regularly; the movements were of good color and 
looked perfectly digested. He had lost weight, strength and 
color very rapidly during the week. The temperature had 
been moderately elevated during the early part of the week, 
but had been normal for three days. 

Physical Examination. He was well developed and nour- 
ished, but had evidently lost considerable weight and color. 
There was no jaundice. The tongue was nearly clean; the 
throat normal. The heart and lungs were normal. The 
abdomen was much enlarged and there was distinct bulging 
in the epigastrium. The superficial abdominal veins were 
moderately enlarged. The upper border of the liver flatness 
in front was at the lower border of the fifth rib; behind, in 
the eighth space on the right and the ninth space on the left 
side. The lower border of the liver reached to the right 
anterior superior spine, ran across the abdomen midway 
between the pubes and the navel and thence nearly to the 
left anterior superior spine. The left border was concealed 
by the greatly enlarged spleen, which filled up the left flank 
and overlapped the liver. The surface of the Tver was 
markedly irregular. Several masses, the size of hens' eggs, 
were easily felt, and there was one, the size of an orange, in 
the epigastrium. The liver was slightly tender. There were 
no evidences of fluid in the abdomen. The kidneys were not 
palpable. There was no edema of the extremities, which were 
normal. There was no spasm or paralysis. The knee-jerks 
were equal and normal. Kernig's sign was absent. There 



2l8 CASE HISTORIES IN PEDIATRICS. 

were numerous lymph nodes, varying in size from that of a 
bean to that of a walnut, in the neck, a few small ones in the 
axillae, and several, the size of marbles, in the groins. 

The urine was normal in color, acid in reaction, of a specific 
gravity of 1,015 an d contained neither albumin, sugar nor 
bile. The sediment showed nothing abnormal. 

Stained specimens of the blood showed slight achromia, but 
no irregularity in the size or shape of the red corpuscles and 
no nucleated forms. There were no plasmodia and no leu- 
cocytosis. There were fifty-four polymorphonuclear neu- 
trophiles to forty-six mononuclear cells. 

Diagnosis. The diagnosis lies between malignant disease 
of the liver and acute lymphatic leukemia in an aleukemic 
stage. The points which suggest leukemia most strongly are 
the enlargement of the spleen and of the peripheral lymph 
nodes. It is true that in very rare instances there are times 
in the course of acute leukemia in which the number of white 
cells is not increased. In such instances, however, the pro- 
portion of mononuclear cells remains much higher than in 
this instance, in which the number of mononuclear cells is not 
much above the normal limit. Primary malignant disease of 
the liver is extremely rare, there being but thirty-nine cases 
on record. The trouble in the liver in this instance is, there- 
fore, almost certainly secondary. The usual location of the 
primary lesion is in the suprarenal capsule. The enlargement 
of the spleen and lymph nodes is, therefore, like that of the 
liver, probably due to metastatic malignant involvement 
rather than to leukemia. The diagnosis of secondary Malig- 
nant Disease of the Liver is. therefore, justified. Sarcoma 
of the suprarenal capsule is much more common than carci- 
noma. The chances are, therefore, that the disease of the 
liver in this instance is sarcoma. The fact that his mother 
had a carcinoma is in all probability merely a coincidence. 

Prognosis. The prognosis is, humanly speaking, abso- 
lutely hopeless. He will probably not live but a few weeks. 

Treatment. It will be well to try the mixed toxins of the 
streptococcus of erysipelas and the bacillus prodigiosus, 
recommended by Coley. Little or nothing can be hoped from 
them, however, in this instance. 



SECTION IX. 

DISEASES OF THE KIDNEYS AND BLADDER. 

CASE 71. Walter B., fourteen years old, had had measles, 
whooping cough, chicken-pox, influenza and tonsillitis, but 
not scarlet fever, diphtheria or rheumatism. His urine had 
been examined from time to time in the past, but had never 
contained albumin. He had an acute attack of appendicitis 
the latter part of December, 1909, which required operation 
and drainage. He had been below par for some time before 
this operation and had not been well since then, although he 
had had no very definite symptoms. He was easily tired, did 
not feel able to go to school and did not care to play. His 
appetite and digestion were good. He had no cough or fever. 
His chief complaint was of pain in the left iliac fossa, which 
was not dependent on either food or exertion. Micturition 
was at times a little painful, but was not increased in fre- 
quency. He thought that he did not pass any more urine than 
normal, and did not have to get up at night. He had always 
been thin and had lost some weight since the operation. He 
was seen at 2 p.m., May 27 ', 1910. 

Physical Examination. He was thin and rather flabby, 
but not pale. He looked pulled down and was very nervous. 
His tongue was clean. His heart was normal except that at 
times the rhythm was a little irregular. The lungs were 
normal. The liver and spleen were not palpable. The ab- 
domen was sunken and showed nothing whatever abnormal 
except the scar of the operation. The kidneys were not 
palpable. The genitals were normal. The extremities were 
normal. There was no spasm or paralysis; the knee-jerks 
were equal and normal. There was no edema and no 
enlargement of the peripheral lymph nodes. 

The freshly passed urine w T as normal in color, clear, alka- 
line in reaction, of a specific gravity of 1,025, an d showed a 
trace of albumin with nitric acid. The centrifugalized sedi- 

219 



220 CASE HISTORIES IN PEDIATRICS. 

ment showed a few small, round cells and no bacteria. The 
gravity sediment showed neither cells, casts nor blood. 

Diagnosis. It is evident, in the first place, that the pain 
in the abdomen has no connection with the albumin in the 
urine. It is almost certainly due to adhesions formed at the 
time of the appendicitis. A bacterial infection of the urinary 
tract can be excluded on the absence of bacteria and pus 
corpuscles in the urine. The other possibilities are chronic 
nephritis and orthostatic albuminuria. His age and the fact 
that he does not get up at night to pass water are much against 
chronic interstitial nephritis. He has not had scarlet fever 
or diphtheria, the usual precursors of chronic parenchymatous 
nephritis at this age, and has never at any time had any 
symptoms of acute nephritis. The absence of all organic 
elements in the sediment, moreover, while possible in chronic 
interstitial nephritis, is very unusual; it practically excludes 
chronic parenchymatous nephritis. The high specific gravity 
is against chronic interstitial nephritis; the small amount of 
urine against chronic parenchymatous nephritis. The normal 
condition of the urine at various examinations in the past is 
also very much against the existence of any form of chronic 
nephritis. His age and slight build are in favor of orthostatic 
albuminuria. So also is the impaired muscular tone resulting 
from his enfeebled condition after the operation, which pre- 
disposes him to lordosis, the probable cause of orthostatic 
albuminuria. Although the diagnosis of orthostatic albumi- 
nuria seems reasonably certain, it will be wise to examine the 
urine further in order to settle the diagnosis. The albumin in 
orthostatic albuminuria is present only in the urine excreted 
when the patient is in the upright position. It is usually 
constantly present in interstitial nephritis or, if not, there is 
no regularity about its appearance. More urine is passed 
during the day than during the night in orthostatic albumi- 
nuria, while the reverse is the case in chronic interstitial 
nephritis. The total amount of the urine is unchanged in 
orthostatic albuminuria, while it is increased in interstitial 
nephritis. 

The twenty-four-hour amount of urine was thirty-one 
ounces. Twelve ounces were passed during the night and 



DISEASES OF THE KIDNEYS AND BLADDER. 221 

nineteen ounces during the day. The urine passed on getting 
up in the morning was pale, clear, acid in reaction, of a specific 
gravity of 1,030, and showed no albumin by either the heat 
or nitric acid tests. That passed during the morning was pale, 
clear, acid in reaction, of a specific gravity of 1,032 and showed 
a trace of albumin by the nitric acid test. That passed dur- 
ing the afternoon was pale, clear, acid in reaction, of a specific 
gravity of 1,030, and showed a slight trace of albumin by 
the nitric acid test. No cells or casts were found in the 
gravity sediment of any of the specimens. The diagnosis of 
Orthostatic Albuminuria is thus confirmed. 

Prognosis. The prognosis of this condition is good. It 
probably never leads to chronic nephritis. The duration is 
indefinite. It will probably persist in this instance until he 
gets back into good physical condition and grows heavier and 
more muscular. 

Treatment. There is no specific treatment. The treat- 
ment consists in regulation of his life with the object of getting 
him into good general condition as soon as possible. It is 
not necessary to diminish the proteids in his diet. It will, 
however, be advisable for him to lie down for a time daily. 



222 CASE HISTORIES IN PEDIATRICS. 

CASE 72. Harry D., eleven years old, had had frequent 
attacks of recurrent vomiting since he was a baby. He had 
had an attack of infantile paralysis, involving both legs and 
one arm, two months before. Nausea and vomiting began 
November 21 and continued in spite of several doses of calo- 
mel, which resulted in a number of large, well-digested move- 
ments. He had taken and retained very little nourishment, 
and had, in consequence, lost considerable weight and strength. 
He had had no fever. The urine passed during the day of the 
26th was clear but small in amount. That night he had con- 
siderable pain in the abdomen, especially on the left side. 
It was not very severe and not paroxysmal. It did not run 
down into the penis, and micturition was not frequent or 
painful. The urine passed during the night was not dimin- 
ished in amount but was distinctly bloody. He was rather 
lame the morning of the 27th, but had no pain. The urine 
continued to be bloody. His bowels moved well, but he 
continued to vomit. His mouth temperature rose to 101 F. 
He was seen in consultation at noon, November 27. 

Physical Examination. He was fairly developed and nour- 
ished and a little pale. His tongue was dry and covered with a 
thin, brown coat. The cardiac area was normal, the sounds 
fairly strong, the action regular, the rate 120. The lungs were 
normal. The liver and spleen were not palpable or enlarged 
to percussion. The abdomen was much sunken. There was 
slight tenderness on deep pressure in the left flank, but no 
muscular spasm, dullness or tumor. The kidneys were not 
palpable and there was no tenderness over the ureters. The 
genitals were normal. The extremities were not examined. 

The urine was red, strongly acid in reaction, of a specific 
gravity of 1,020 and contained a trace of albumin, consider- 
able acetone and a little diacetic acid, but no sugar. The 
sediment was very abundant and was almost entirely com- 
posed of acid sodium urate crystals. It also contained a 
moderate number of normal red blood corpuscles and an 
occasional leucocyte, but no other cells or casts. 

Diagnosis. He undoubtedly has one of his ordinary attacks 
of recurrent vomiting. The disturbance of metabolism at the 
bottom of the attack, the insufficient supply of food, or both 



DISEASES OF THE KIDNEYS AND BLADDER. 223 

together, explain the presence of acetone and diacetic acid 
in the urine. The pain in the abdomen and the hematuria 
require further explanation. The condition is an acute one, 
and the examination of the kidneys shows nothing abnormal. 
It is unnecessary, therefore, to consider such conditions as 
sarcoma or tuberculosis of the kidney. Acute nephritis is 
seldom accompanied by pain. It can be excluded on the 
absence of cells and casts. The most probable explanation 
would, at first thought, seem to be a fenal calculus. The 
pain was, however, not localized or paroxysmal and did not 
run down into the penis. Micturition was not painful or 
increased in frequency. These facts do not, of course, rule 
out a renal calculus, but make it less probable than at first 
appeared. A large number of sharp crystals in the urine 
might easily irritate the kidney sufficiently to cause the sort 
of pain present in this instance and hematuria. It is hard to 
conceive of anything sharper than the crystals of acid sodium 
urate which were so numerous in this boy's urine. Irritation 
of the kidneys and urinary tract from crystals of acid sodium 
urate is, therefore, the most reasonable explanation of the 
Hematuria. The disturbance of metabolism at the root of 
the recurrent vomiting, together with thatdue to an insuffi- 
cient supply of food, and the concentrationof the urine resulting 
from an insufficient supply of water, account satisfactorily for 
the formation of the acid sodium urate crystals. 

Prognosis. The prognosis is good. The attack of recur- 
rent vomiting will yield quickly to treatment. The hematuria 
will cease with relief of the attack of vomiting, and probably 
sooner if more water can be introduced into the system. 

Treatment. See Case 12 for the treatment of recurrent 
vomiting. The indications for the treatment of the hematuria 
are to increase the amount of the urine and diminish its 
acidity. These can best be. met by high injections of from 
eight to twelve ounces of a solution of one teaspoonful of 
bicarbonate of soda in eight ounces of water every four 
hours. The same solution may be given by mouth, in tea- 
spoonful or tablespoonful doses, every fifteen or twenty min- 
utes. Fortunately, this method of treatment is also the one 
most useful in recurrent vomiting. 



224 CASE HISTORIES IN PEDIATRICS. 

CASE 73. Frances S., two and one-half years old, was the 
child of healthy parents. Three other children were living 
and well; none had died, but there had been two miscarriages. 
There was no history of tuberculosis in the family and there 
had been no known exposure to it. 

She had always been well and strong. She had a cough for 
a few days about the 10th of August. Her parents noticed 
at this time that her eyelids were a little swollen in the morn- 
ing. Not much was thought of it, however, as the swelling 
was gone by noon. It became more marked about a week 
later and had persisted. Swelling of the legs and abdomen 
also appeared in a few days and had steadily increased. It 
was noticed at this time that she was not passing as much 
urine as usual. She was put on an exclusively milk diet, which 
she took well. Her bowels had been kept well open by 
cathartics. She was admitted to the Children's Hospital, 
September 7. 

Physical Examination. She was markedly pale, but did 
not appear very sick. There was marked general anasarca. 
Her eyelids were so much swollen that it was difficult to see 
her eyeballs. The pupils were equal and reacted to light. 
Her tongue was considerably coated. Her teeth were in bad 
condition and there was a slight pyorrhea alveolaris. The 
tonsils were ragged and injected. There was a venous hum 
in the neck. The cardiac impulse was neither visible nor 
palpable, probably because of the anasarca. The upper 
border of the relative cardiac dullness was in the second space, 
the right border 2\ cm. to the right, and the left border 5 cm. 
to the left of the median line. The first sound was of good 
strength and was followed at the mitral area by a soft murmur, 
which was not transmitted. The second pulmonic sound was 
not accentuated. There was slight dullness, with diminished 
vesicular respiration and numerous fine, moist rales, below 
the sixth rib and extending outward to the mid-axillary line 
on both sides. The upper border of the liver flatness was in 
the fifth space in the nipple line; the edge was not palpable. 
The spleen was not palpable. The abdomen was much and 
symmetrically distended. The superficial veins were not 
enlarged. The percussion note was flat over the whole ab- 



DISEASES OF THE KIDNEYS AND BLADDER. 225 

domen except in the epigastrium, where it was tympanitic. 
The upper border of the flat area was concave. The area of 
flatness changed with change of position, and there was a 
fluid wave. There was no spasm or paralysis of the extremi- 
ties. The knee-jerks were equal and normal. There was no 
enlargement of the peripheral lymph nodes. There was no 
eruption or desquamation. The rectal temperature was 
ioo° F., the pulse no, the respiration 30. 

Four ounces of urine were passed in the first twenty-four 
hours of her stay in the hospital. It was brownish in color, 
turbid, acid, of a specific gravity of 1,030 and contained 
twenty grams of albumin per liter, but no sugar or acetone. 
The sediment showed large numbers of hyaline, fine and 
coarse granular casts, and a few blood casts, as well as large 
numbers of red and white blood cells. 

Diagnosis. She undoubtedly has Acute Nephritis. The 
normal size of the heart and the absence of accentuation of 
the second aortic sound prove that there is no chronic trouble 
back of it. The etiology is obscure. The ragged, injected 
tonsils or the diseased teeth and gums may have been the 
portal of entry for the infection. The venous hum in the neck 
and the murmur in the heart are anemic in origin and 
unimportant. 

Prognosis. The prognosis is grave. She is passing but little 
urine and has general anasarca, ascites and edema of the 
lungs. A more definite prognosis can be given in a few T days 
after it has been seen how well she responds to treatment. 
If she responds quickly, she w T ill probably recover entirely in 
time. If she does not respond, she will probably not live 
many days. 

Treatment. Her kidneys are congested and engorged with 
blood, the glomeruli and tubules are blocked and the epithe- 
lium degenerated. They are able' to excrete but little and are 
practically impervious to water. If they were not, she would 
not be edematous. Water must, therefore, be stopped en- 
tirely for the present. It ought not to be given again until the 
kidneys have begun to excrete fairly freely and the edema and 
ascites are diminishing. 

Her kidneys should be spared the work of excretion as 



226 CASE HISTORIES IN PEDIATRICS. 

much as possible. The products of the metabolism of certain 
foods are excreted with difficulty, and those of others easily. 
Those substances which are excreted with the most difficulty 
are urea, creatinin and phosphoric acid. Urea is derived 
from proteids: meat, eggs and milk. It would seem wise, 
then, to cut out all proteids from her diet. Nothing is gained, 
however, by reducing them below a certain point, because, 
even in starvation, a certain amount of urea is formed as the 
result of the destruction of the body tissues. If enough pro- 
teid is given to cover this nitrogenous waste, the body tissues 
are saved and the kidneys are not worked any harder than 
when no proteid is given. The amount of proteid required to 
balance the necessary nitrogenous metabolism of the body is 
known as the minimum proteid need, and is, in a child of this 
age, about twenty grams. Creatinin is derived from creatin. 
This is contained in meat and especially in meat extracts and 
meat broths. Meat extracts and broths contain little else and 
have but little nutritive value. They should, therefore, be 
entirely excluded from her diet. Milk contains but little 
creatinin. Phosphoric acid is present in large amounts in 
meats, yolk of egg, milk and many vegetables. The addition 
of calcium carbonate to the food, however, prevents its 
passage through the kidneys and causes it to be excreted by 
the intestines. The products of the metabolism of fat, sugars 
and starches are excreted by the kidneys without much 
difficulty. 

It is not only necessary, however, to cover her proteid need, 
but also to cover her caloric needs. These are a little under 
1,000 calories. She can get along very well for a time, how- 
ever, on 800 or 900 calories. 

The problem is, then, to lay out a diet for her which will 
contain 800 or 900 calories and about 20 grams of proteid. 
The best form in which to give the proteid is milk. Six hun- 
dred cubic centimeters of milk will give 21 grams of proteid, 
but only about 400 calories. If milk enough is given to fur- 
nish 900 calories it will contain 47 grams of proteid, which is 
more than double the minimum proteid need. The disad- 
vantages of an exclusively milk diet are thus evident. If 
200 ccm. of gravity cream (16% fat) is substituted for 200 



DISEASES OF THE KIDNEYS AND BLADDER. 



227 



ccm. of milk, the mixture will provide 600 calories. The 
remainder of the caloric need can be met by giving sugar and 
starch. For example, as is shown in the following table of 
food values, two tablespoonfuls of cereal will give 50 cal- 
ories, two teaspoonfuls of sugar 50 calories, one slice of bread 
75 calories, and a piece of butter one inch square and one- 
half inch thick, about 65 calories, making a total of 840 cal- 
ories, which covers fairly satisfactorily her caloric needs, and 
does not add much to the proteids. 

Table of Food Values. 







Grams. 






Calories. 


F. 


c. 


p. 


Whole milk, 1 quart, 


670 


38 


43 


34 


Skim milk, 1 quart, 


400 


10 


43 


35 


Gravity cream, 1 pint, 


860 


77 


22 


14 


Buttermilk, 1 quart, 


360 


5 


43 


35 


Whey, 1 quart, 


260 


5 


43 


9 


Beef juice, 1 ounce, 


10 






2 


Crackers, 1 ounce, 1 


120 


3 


20 


3 


Bread, 1 slice, 3 


75 


o-5 


15 


3 


Zwiebach, 1 slice, 4 


120 


3 


20 


3 


Shredded wheat biscuit, 


105 


0-5 


22 


3 


Oatmeal and other cereals (cooked), 1 tablespoonful, 


25 




5-5 


1 


Rice (cooked), 1 tablespoonful, 


45 




10 


1 


Potato, size of large egg, 


100 




20 


2 


Macaroni (cooked), 1 tablespoonful, 


30 


0-5 


5 


1 


( Whole, 


72 


5 




7 


Egg ] Yolk, 


60 


5 




4 


( White, 


12 






3 


Fish I ( coo ^ ea1 )' I ounce, 2 


60 


3 




7 


Butter, ij inches cube = 1 ounce, 


225 


24 






Olive oil, I tablespoonful, 


125 


14 






Sugar \ Cane, 1 rounded teaspoonful, 
I Milk, 1 rounded tablespoonful, 


25 




6 




60 




15 




Green peas (cooked), 1 tablespoonful, 


40 




7 


3 


Carrots ) 










Squash >- (cooked), 1 tablespoonful, 


30 




6 


1 


Turnip ) 










Orange, medium sized, 


50 




13 




Apple, medium sized, 


70 




17 





1 Crackers vary so much in size that they must be weighed to determine how many it takes to 
weigh an ounce. 

2 The lean of a lamb chop weighs about an ounce; so does a piece of meat about i$ inches cube. 

3 Bread, one slice = four inches square and three-eighths inch thick = i ounce. 

4 Zwiebach , one slice = large slice . 

Clear soups and broths made without rice or barley have practically no nutritive value. 
The nutritive value of the " fodder " vegetables, such as spinach, string beans, asparagus, lettuce, 
tomatoes and cucumbers, is so slight that it may be disregarded. 

The addition of 30 grains of prepared chalk to the milk and 
cream mixture will probably render the phosphoric acid prac- 
tically inert. The chief objection to the milk in this instance 



228 CASE HISTORIES IN PEDIATRICS. 

is the water which it contains, a little more than a pint. In 
her present condition even this amount of water may do harm. 
It will be wise, therefore, to disregard her proteid needs for 
twenty-four or forty-eight hours and give her nothing but 
carbohydrates and fat. In fact, it will do her no harm if she 
takes no nourishment at all for twenty-four or forty-eight 
hours. 

There are no drugs which can directly aid her kidneys to do 
their work. Digitalis and drugs of its class have no direct 
action on the kidneys, but increase the flow of urine by 
strengthening the action of the heart and thus sending more 
blood through the kidneys. Her kidneys are already engorged 
with blood. It is, therefore, not only irrational to increase 
the flow of blood to her kidneys, but also very likely to in- 
crease the trouble. Caffein, theobromin and their prepara- 
tions have a direct stimulant action on the renal epithelium. 
Her renal epithelium is in no condition to respond to stimula- 
tion and, moreover, stimulation may do harm by increasing 
the inflammation. The action of alkalies is probably the 
same as that of other diffusible bodies which are excreted by 
the kidneys and which during their excretion increase the 
flow of urine. As the object of the treatment is to spare the 
kidneys, it hardly seems rational to give alkalies at this time 
to increase the work which they have to do. All drug treat- 
ment is, therefore, contra-indicated. 

It is possible, however, to spare the kidneys by making the 
bowels do part of their work. She must, therefore, be made 
to have three or four large, watery movements of the bowels 
daily. Compound jalap powder, in doses of fifteen grains, or 
compound licorice powder, in doses of from one to two tea- 
spoonfuls, will probably do this best in this instance, as she 
will probably not object to them as she would to concentrated 
solutions of Epsom salts, the ideal cathartic in this condition. 
The free catharsis will also help to diminish the edema. 

It is important to get rid of the edema. The best way to 
accomplish this is by free diaphoresis. This spares the kid- 
neys by getting the water out of the system, but does not save 
them in other ways, because it is certain that but little urea 
is eliminated in this way, and there is no proof that toxic 



DISEASES OF THE KIDNEYS AXD BLADDER. 2 29 

substances are excreted by the skin. Pilocarpin is the only 
diaphoretic drug powerful enough to be of any practical 
utility. It is, however, a very dangerous drug on account of 
its liability to cause edema of the lungs, and should never be 
used except in an emergency. Her condition is not serious 
enough to justify its use. The application of heat externally 
is far safer and usually more effectual. It is very difficult to 
keep a child in a hot-air bath long enough to get good results, 
as they soon become restless and kick the coverings loose. 
They object much less to hot packs. She should be wrapped 
in a blanket and put in a tub of water between 105 F. and 
110 F. and kept there from ten to fifteen minutes. She 
should then be taken out. wrapped in a hot, dry blanket and 
kept surrounded by heaters for from one-half to two hours. 
This should be repeated daily as long as there is much edema. 



230 CASE HISTORIES IN PEDIATRICS. 

CASE 74. Nora C, aged thirteen months, lived in a town 
in which malaria was common. She was breast-fed for five 
months. She was then weaned gradually and put ona" hit- 
or-miss " mixture of top milk with Mellin's Food, on which 
she did very well. Early in August, about three weeks before 
she was seen, she began to be feverish and was given calomel. 
The next day she was better, but two days later she had a 
chill. She had had no chills since then, but had sweat pro- 
fusely at times and had lost much weight. Her temperature 
had not been normal but once in the last two weeks, and had 
been very irregular. The food had been changed to a weak 
top milk and barley water mixture. She had not vomited, 
but had been constipated. The movements, however, were 
normal in character. The Widal reaction, tested three days 
before, was negative. The diagnosis of malaria having been 
made, on the basis of the irregular temperature, the chill, the 
sweating and the negative Widal test, she had been given 
quinine in considerable doses during the last six days without, 
however, any improvement in the symptoms. 

Physical Examination. She was well developed and nour- 
ished, but a little pale and flabby. The anterior fontanelle 
was 3 cm. in diameter and level. She was irritable, but not 
stupid. Her mouth and throat showed nothing abnormal. 
She had eight teeth. There was no rosary. The heart, lungs 
and abdomen showed nothing abnormal. The liver was 
palpable 2 cm. below the costal border in the nipple line. 
The spleen was not palpable. The extremities were normal. 
There was no spasm or paralysis. The knee-jerks were equal 
and normal. There was no enlargement of the peripheral 
lymph nodes. 

The blood showed 80% of hemoglobin, and 37,600 white 
corpuscles. 

Diagnosis. The negative Widal test and the leucocytosis 
rule out typhoid fever. The absence of enlargement of the 
spleen and the leucocytosis, as well as the failure of the quinine 
to influence the symptoms, exclude malaria. The fever, chills, 
sweating and leucocytosis point to a purulent process some- 
where. There is nothing about the symptomatology to sug- 
gest the location of this process. In such instances the middle 



DISEASES OF THE KIDNEYS AND BLADDER. 23 1 

ear and the urine must always be investigated, since in infancy 
both otitis media and pyelitis often cause marked general, 
without any local, symptoms. If the trouble is not found in 
one, it is almost certain to be found in the other. If both are 
normal, the trouble is most often tubercular. 

The ears were examined and found normal. 

The fresh urine was cloudy, pale, neutral in reaction and 
contained a very slight trace of albumin. The sediment ob- 
tained by centrifugalization showed very many pus cells, 
free and in clumps, a few small round, squamous, oval and 
caudate cells, and many motile bacteria. These bacteria 
were later shown to be colon bacilli. 

The diagnosis is, therefore, Pyelitis, or, better, infection 
of the urinary tract by the bacillus coli. 

Prognosis. There is practically no danger as to life. She 
will probably recover in a few weeks, but there is a reasonable 
probability that the condition will persist, with intermissions, 
for many months. In some instances the urine continues to 
contain bacteria, and at times pus, for years, although there 
is no constitutional disturbance. There is very little danger 
that the process will extend to the kidney tissue or that it 
will involve anything more than the superficial layers of the 
pelvis and bladder. 

Treatment. Local treatment of the bladder is of compara- 
tively little value because the infection is not localized in 
the bladder but involves the whole urinary tract. It is better, 
therefore, not to use it in this instance. Hexamethylenamin, 
the best drug of its class, liberates formaldehyde readily in the 
urine and has a strong antiseptic action. Unfortunately the 
colon bacillus is comparatively insusceptible to its action. 
Hexamethylenamin is usually less effective than the alkalies, 
which, in spite of the fact that the colon bacillus grows more 
luxuriantly in alkaline than in acid media, are often very 
useful. It will be well, therefore, to give her ten grains of the 
citrate of potash, well diluted, three times a day. If this dose 
is not sufficient to make the urine highly alkaline, larger doses 
must be given. If the urine does not clear up under this treat- 
ment, hexamethylenamin, in doses of from one-half grain to 
one grain, three times a day, should be tried. If the trouble 



232 CASE HISTORIES IN PEDIATRICS. 

still persists, it will be well to try the effect of suddenly chang- 
ing the reaction of the urine every three of four days, which 
sometimes clears up the urine very quickly. It can be made 
alkaline with the citrate of potash and acid with benzoic acid, 
in doses of from one to three grains, three times a day. 

If the trouble still continues, the vaccine treatment may be 
tried, but too much must not be hoped from it. In some in- 
stances it works very well ; in others it has no effect whatever. 
An autogenous vaccine must be used. It will be well to begin 
with 25,000,000 every three or four days, increasing the dose 
rather rapidly to 100,000,000. The treatment can be carried 
on satisfactorily without determinations of the opsonic index. 



DISEASES OF THE KIDNEYS AND BLADDER. 233 

CASE 75. Mary W., aged seven months, was taken sud- 
denly sick with high fever the night of July 7. No cause for 
the fever could be made out. The temperature ran between 
103 F. and 105 F. up to the time she was seen in consulta- 
tion, July 14. The physical examination had always been 
negative. She had had a slight cough in the beginning. She 
had taken heY food poorly, but had vomited but once. The 
bowels had moved regularly and the movements had been 
normal. She had always been conscious, but during the last 
two days had seemed tender all over and had held her head 
backward. During the last two or three days micturition had 
been painful but not increased in frequency, and the urine 
had left greenish-yellow spots on the diapers. 

Physical Examination. She was well developed and nour- 
ished, but had evidently lost some weight and color. She was 
conscious, but irritable. The anterior fontanelle w^as 3 cm. 
in diameter and depressed. There was no rigidity or tender- 
ness of the neck and no neck sign. The pupils were equal and 
reacted to light. The ear-drums were normal. The tongue 
was dry, the throat and gums normal. There were four teeth. 
The heart, lungs and abdomen were normal. The liver was 
just palpable in the nipple line. The spleen and kidneys were 
not palpable. The extremities were normal. There was no 
spasm or paralysis. The knee-jerks were equal and normal. 
Kernig's sign w^as absent and there was no contralateral 
reflex. There was no enlargement of the peripheral lymph 
nodes. The rectal temperature was 103. 6° F., the pulse 160, 
the respiration 40. 

A stool which was seen was loose, smooth, yellow and 
contained no curds or mucus. There were several small 
spots, looking like pus, on the diaper. 

Diagnosis. The most probable diseases in this instance are 
pneumonia, cerebrospinal meningitis and pyelitis. The 
sudden onset, the continued high fever and the slight cough 
suggest pneumonia, but the absence of physical signs after a 
week and the fact that the rate of the respiration is not in- 
creased out of proportion to that of the pulse make it ex- 
tremely improbable. Meningitis is suggested by the history 
of general tenderness and of the tendency to hold the head 



234 CASE HISTORIES IN PEDIATRICS. 

backward. It can be ruled out at once, however, on the de- 
pressed fontanelle and the absence of all signs of meningeal 
irritation or increased cerebral pressure. A lumbar puncture 
was done, however, at the request of the attending physician. 
The fluid ran out slowly, drop by drop, was perfectly clear, 
did not form a fibrin clot and contained no cells or bacteria 
(for description of the cerebrospinal fluid in health and 
disease see Case 38), thus proving that the trouble was not 
meningitis. 

The continued high fever without physical signs and with 
normal ears suggests at once the possibility of pyelitis. The 
painful micturition and the greenish-yellow spots on the 
diapers make this diagnosis almost certain. The urine was, 
therefore, obtained with a catheter. It was pale, turbid, acid 
in reaction and contained many pus cells and motile bacteria, 
which were later proved to be colon bacilli. The results of 
this examination confirm, of course, the diagnosis of 
Pyelitis. 

Prognosis. See Case 74. 

Treatment. See Case 74. 



DISEASES OF THE KIDNEYS AND BLADDER. 235 

CASE 76. Catherine R. was the fourth child of healthy 
parents. There had been no deaths or miscarriages. She had 
not, as far as known, been exposed to tuberculosis. 

She was born at full term after a normal labor and was 
normal at birth. She was breast-fed, but was given in addi- 
tion bread, potatoes and, in fact, a taste of almost everything 
on the table. Her digestion was good in spite of her faulty 
diet, and she gained steadily in weight up to an attack of 
bronchitis, when she was nine months old. She did not seem 
as well after the bronchitis and ceased to gain, although her 
appetite and digestion continued good. Enlargement of the 
abdomen was noticed w T hen she was nine and a half months 
old, and had increased rapidly since then. The abdomen had 
not been tender and the urine had never been red. She was 
seen in consultation when ten months old. 

Physical Examination. She was fairly developed and nour- 
ished. Her skin was pale, but her lips w T ere red. The anterior 
fontanelle was 2 cm. in diameter and level. She had four 
teeth. Her tongue was clean and her throat normal. There 
was no rosary. Her heart and lungs were normal. The liver 
was palpable 3 cm. below the costal border in the nipple line. 
The spleen was not palpable. The left half of the abdomen 
was nearly filled by a hard, smooth, rounded mass. It had 
no definite borders, was flat on percussion and not at all 
tender. It filled the flank and evidently originated deep in 
the abdomen. It was not movable and its position was not 
influenced by the respiration. The abdomen showed nothing 
else abnormal. The extremities were normal and there was 
no edema. There was no spasm or paralysis; the knee-jerks 
were equal and normal; Kernig's sign was absent. There 
was no enlargement of the peripheral lymph nodes. The 
mass could be felt on rectal examination. 

Stained smears of the blood showed no changes in the red 
corpuscles and no leucocytosis. A large majority of the 
white corpuscles were lymphocytes, although there was a 
slight excess of eosinophiles. 

Diagnosis. The location of the mass deep down in the 
flank and its rounded character, without definite borders, 
prove that it is not a tumor of the spleen. The tumors in 



22,6 CASE HISTORIES IN PEDIATRICS. 

caseous or fibrocaseous tubercular peritonitis are not as large, 
are irregular in outline and usually multiple. Enlargement 
of the retroperitoneal lymph nodes might cause a tumor in 
this region, but it would not be as large and would be irregular 
in outline. The only organ whose enlargement would cause 
a tumor in this location is the left kidney. This tumor must, 
therefore, be the left kidney. The possible causes of enlarge- 
ment of the kidney are hydronephrosis, pyonephrosis and 
sarcoma. Hydronephrosis is extremely rare at this age, she 
has had no attacks of pain and there is no fluctuation. Pyo- 
nephrosis is also extremely uncommon at this age, there is 
nothing in her history to suggest an infection of the urinary 
tract, she has no fever or leucocytosis, her general condition 
is good and there is no fluctuation. Sarcoma of the kidney is 
more common at this age than at any other, it develops 
insidiously without much disturbance of the nutrition, and 
the tumor in this instance corresponds in its physical char- 
acteristics to those of sarcoma of the kidney. The eosino- 
philia is also suggestive of a new growth. The absence of 
hematuria does not count against sarcoma, because it occurs 
in but a small proportion of the cases. The diagnosis of 
Sarcoma of the Kidney is, therefore, justified. 

Prognosis. The prognosis without operation is absolutely 
hopeless. She will probably not live more than three or four 
months. It is not much better with operation. The opera- 
tion is a serious one and often fatal. Recurrence takes place 
in the neighboring tissues in the large majority of those that 
survive the operation. A few recover. 

Treatment. The only treatment is the immediate removal 
of the tumor. 



SECTION X. 
DISEASES OF THE BLOOD. 

CASE 77. Mary J. was seen when twenty- three months 
old. Her mother had died soon after her birth of a cancer 
which she had had during the pregnancy. She had always 
been fed exclusively on modified milk. She had had no ill- 
nesses except several slight digestive upsets when about a 
year old. She took her food well and did not vomit, although 
at times she seemed nauseated. Her bowels moved regularly 
and the movements were normal. She was listless and quiet 
and her temperature was usually a little subnormal. 

Physical Examination. She was well developed and nour- 
ished, but moderately pale. The anterior fontanelle was closed 
and her head was of good shape. She had twelve teeth. Her 
tongue was clean and her mouth and throat normal. There 
was a venous hum in the neck. The heart was normal 
except for a systolic murmur at the pulmonic area, which was 
not transmitted. The lungs were normal. There was a 
slight rosary. The level of the abdomen was that of the 
thorax. The liver was palpable 1 cm. below the costal border 
in the nipple line. The spleen was not palpable. The ex- 
tremities were normal. There was no spasm or paralysis. 
The knee-jerks were equal and normal. There was no 
enlargement of the peripheral lymph nodes. 

The urine was pale, clear, faintly acid in reaction, of a 
specific gravity of 1,012, and contained neither albumin nor 
sugar. The sediment showed nothing abnormal. 

Blood. 
Hemoglobin, 50% (normal = 70%) 

Red corpuscles, 5,122,000 (normal == 5,500,000 to 6,000,000) 
White corpuscles, 11,300 (normal = 10,000 to 12,000) 

Mononuclears, 3*%^ 

Polynuclear neutrophiles, 65% 

Eosinophiles , I % 

Mast cells, 3% J 

237 



*- (normal) 



230 CASE HISTORIES IN PEDIATRICS. 

The red corpuscles showed some variation in size and shape 
and some achromia, but no nucleated forms. 

Diagnosis. The venous hum in the neck and the systolic 
murmur at the pulmonic area are, of course, merely signs of 
the very evident anemia. The percentage of hemoglobin is 
about seventy per cent of the normal, while the number of 
red corpuscles is about ninety per cent of the normal. The 
morphological changes in the red corpuscles are so slight that 
they are of but little importance. The blood picture is, there- 
fore, that of chlorosis. The diagnosis of chlorosis is for many 
reasons, however, not justified in this instance, in spite of the 
characteristic blood picture. 

In the first place, the percentage of hemoglobin is always 
relatively low in infancy. This is presumably due to the 
fact that the infant normally receives an insufficient supply 
of iron in its food and that the reserve of iron present in the 
liver at birth is not large enough to keep the percentage of 
hemoglobin at the adult standard. The reserve of iron is, 
moreover, often insufficient, and in any event is compara- 
tively easily exhausted. It is seldom sufficient to outlast the 
first year. This relative disproportion between the hemo- 
globin and the number of red corpuscles, when compared 
with the adult standard, is almost always exaggerated in the 
blood diseases of infancy. 

This infant was, on account of her mother's illness during 
the pregnancy, probably born with an insufficient reserve of 
iron. She has never had any food but milk, which does not 
contain enough iron to meet the needs of the normal infant's 
system. Her reserve, being insufficient, was undoubtedly 
exhausted long before the end of the first year, so that for a 
year or more she has been unable to make up for the lack of 
iron in her food and has been falling more and more behind. 
That is, the causes which make the hemoglobin low under 
normal conditions in infancy are much exaggerated in her 
case. The diagnosis of chlorosis is, therefore, not justified 
in this instance. The real condition is a Secondary Anemia, 
due to the long-continued exclusive milk diet. 

Further evidence against the diagnosis of chlorosis in these 
cases is that they occur indifferently in boys and girls, and 



DISEASES OF THE BLOOD. 239 

that they have no pathologic connection with the nervous or 
genital systems. 

Prognosis. The addition of other foods to her diet and the 
administration of iron will improve the condition of the 
blood very rapidly. 

Treatment. Beef juice and egg should be at once added to 
her diet because of the iron which they contain. Starchy foods 
should also be added. She is old enough to digest them and 
needs a more varied diet in order to thrive. The best forms 
of iron for her are the saccharated carbonate and ferratin. 
The former may be given in five-grain and the latter in three- 
grain doses, three times daily, after food. 



24O CASE HISTORIES IN PEDIATRICS. 

CASE 78. Alma H., seven months old, was the second 
child of healthy parents. There was no tuberculosis in the 
family and there had been no known exposure to tuber- 
culosis. She was born at full term after a normal labor, 
was normal at birth and weighed ten pounds. She had had 
nothing but the breast and had always . done well. The 
outside of the house had been painted just before the onset of 
her illness. Her mother also menstruated for the first time 
just at the time of the onset. Her parents affirmed that she 
was perfectly well and had a good color on April 2. Marked 
pallor was noted the next day. She had had no hemorrhages 
or other symptoms of illness. The pallor became yellowish 
on April 6 and the mucous membranes pale on April 7. 
There had been no increase in the pallor up to April 1 1 , when 
she was seen. The conjunctivae had not been yellow, the 
movements had been dark green in color and the urine had 
not contained bile. She had had no hemorrhages and had 
not been tender. She had taken her food well and had not 
vomited. She had had no fever, but at times had seemed 
chilly and had had cold and blue extremities, but no sweat- 
ing. She had become very quiet, but was not fussy. 

Physical Examination. She was decidedly apathetic. She 
was well developed and nourished, but very pale. The skin 
had a decided yellowish tinge, but the conjunctivae were clear. 
The anterior fontanelle was 2 cm. in diameter and level. 
There was no rigidity of the neck and the head was of good 
shape. The tongue was clean; the mouth, gums and throat 
normal. There were no teeth. There was a slight venous 
hum in the neck. There was no rosary. The heart was nor- 
mal except for a slight systolic murmur at the pulmonic 
area, which was not transmitted. The lungs and abdomen 
were normal. The liver was palpable 3 cm. below the costal 
border in the nipple line. The spleen was not palpable. 
There was no tenderness or swelling of the extremities except 
a little puffiness of the feet. There was also a little puffiness 
about the eyes. There was no spasm or paralysis. The knee- 
jerks were equal and normal. There was no enlargement of 
the peripheral lymph nodes. There were no hemorrhages 
into the skin and no eruption or scars of old eruptions. 



diseases of the blood. 24i 

Blood. 

Hemoglobin, 20% (normal = 70%) 

Red corpuscles, 1,492,000 (normal = 5,500,000 to 6,000,000) 

White corpuscles, 11,000 (normal = 10,000 to 14,000) 

Small mononuclears, 68% (normal = 40% to 50%) 

Large mononuclears, 7% (normal = 10%) 

Polynuclear neutrophiles, 21% (normal = 35% to 45%) 

Eosinophiles, 4% (normal = 1% to 5%) 

The red corpuscles showed marked variation in size, the 
tendency being toward large forms. There was slight 
poikilocytosis and moderate polychromatophilia, but no 
stippling. Three normoblasts were seen in counting one 
hundred white cells. Some of the white cells were very 
large, looking like large cells from the bone marrow, and were 
throwing off blood plates. There was a large increase in the 
number of blood plates. No malarial organisms were seen. 

Diagnosis. It is very hard to believe that, in the absence 
of hemorrhages, the anemia developed as rapidly as the par- 
ents affirm. The blood picture is that of a more chronic con- 
dition, and it seems probable, therefore, that the parents did 
not notice the condition until it was fully developed. It is 
also difficult to believe that the painting of the house or the 
mother's menstruation had anything to do with its develop- 
ment. The absence of stippling of the red cells is much against 
lead poisoning. Menstruation sometimes causes disturbances 
of digestion, but not anemia. It is more probable that the 
breast milk, while suitable in other ways, was deficient in 
iron, and that after the reserve supply in the liver was 
exhausted the anemia developed gradually. Scurvy can be 
ruled out as a cause on the absence of tenderness and swelling 
of the extremities and of hemorrhages. Malaria can be 
excluded on the absence of plasmodia in the blood. 

The morphological changes in the red corpuscles, the 
predominance of the large over the small forms of red cells, 
the presence of nucleated cells and the large percentage of 
mononuclear leucocytes would in the adult point strongly 
toward pernicious anemia. The tendency common to all the 
anemias of infancy to revert to a younger type of blood and 
the normal preponderance of mononuclear leucocytes and of 



242 CASE HISTORIES IN PEDIATRICS. 

greater variation in their size make these points of practically 
no importance in the diagnosis of pernicious anemia in in- 
fancy. In all probability, moreover, pernicious anemia does 
not occur at this age. The large number of blood plates 
present in this instance would exclude it, even in an adult. 

Acute lymphatic leukemia in an aleukemic stage is sug- 
gested to a certain extent by the changes in the red cells and 
the comparatively large proportion of mononuclear leuco- 
cytes. The absence of enlargement of the spleen and lymph 
nodes and the age are much against it. The slight signifi- 
cance of the changes in the red cells and of the excess 
of mononuclear leucocytes has already been explained. 
The large number of blood plates practically excludes 
leukemia. 

There is nothing about the blood picture which is in any 
way inconsistent with a secondary anemia in infancy. A 
diagnosis of Secondary Anemia is, therefore, justified, a 
possible cause being a deficiency of iron in the mother's milk. 

Prognosis. The condition of the blood will undoubtedly 
improve rapidly if iron is given. 

Treatment. The baby has done so well in every other way 
on its mother's milk that it is unwise to wean it, since any 
deficiency of iron in the milk can be very easily remedied by 
the administration of iron. This may be given by mouth in 
the form of the saccharated carbonate or of ferratin. When 
the anemia is as marked as it is in this instance it is better, 
however, to give it subcutaneously, because the improvement 
begins so much sooner and is so much more rapid than when 
it is given in the ordinary way. The best form of iron for 
subcutaneous use is the aqueous solution of the citrate. 
This can be put up in pearls and sterilized, and when pre- 
pared in this way remains sterile indefinitely. It is not irri- 
tating. If given subcutaneously, the injection rarely causes 
much pain, but, if given intramuscularly, it is often very 
painful and sometimes causes slight symptoms of shock. It 
must be given with a glass syringe with asbestos packing and 
a platinum needle. The syringe and needle must, of course, 
be sterilized. The dose for this infant is three quarters of a 
grain, every other day. 



DISEASES OF THE BLOOD. 



243 



CASE 79. Jennie R., the daughter of healthy parents, 
was one of twins. The other had always been well. Another 
child was well, while a fourth had died in infancy of " sum- 
mer complaint." She was nursed for five weeks, after which 
she was given modified milk, prepared at a laboratory, for 
three weeks. She had been fed since this time on a modified 
milk, prepared at home. The mixture, which was a Aveak 
one, had not been changed, however, for seven months. 
During this time she had had no disturbance of digestion, 
but had gained very slowly. She had a slight attack of diar- 
rhea when nine months old, which yielded quickly to treat- 
ment and was followed by constipation. Since then she had 
taken a stronger modification of milk and had had no dis- 




Fig. 7. Jennie R. Case 79. 

turbance of digestion. She was seen when ten months old 
because she was not thriving. 

Physical Examination. She was fairly developed and 
nourished. There was moderate pallor of the skin and 
mucous membranes. The anterior fontanelle was 3 cm. in 
diameter and level. The head was flattened on top and be- 
hind, but there was no craniotabes. There were two teeth. 
She sat alone feebly, but with the spine straight. There was 
a marked rosary. There was slight retraction of the chest at 
the insertion of the diaphragm. The heart and lungs were 
normal. The abdomen was distended but otherwise normal, 
except for a slight umbilical hernia. The upper border of the 



244 CASE HISTORIES IN PEDIATRICS. 

liver flatness was at the upper border of the fifth rib; the 
lower border of the liver was palpable 3 cm. below the costal 
border in the nipple line. The spleen was felt running out 
from beneath the costal border in the left anterior axillary 
line to the right of the umbilicus, then downward and back- 
ward to the left anterior superior spine and backward into 
the loin. The surface was smooth, the consistency firm. 
The notch was felt distinctly in the left nipple line, midway 
between the costal border and the navel. The extremities 
were normal except for a moderate enlargement of the epi- 
physes at the wrists. There was a slight general enlargement 
of the peripheral lymph nodes. She weighed ten pounds and 
two ounces. 

The urine was pale, acid, of a specific gravity of 1,015 and 
contained no albumin or sugar. 

Blood. 

Hemoglobin, 40% (normal = 70%) 

Red corpuscles, 4,000,000 (normal = 5,500,000 to 6,000,000) 

White corpuscles, 18,750 (normal = 10,000 to 12,000) 

Small mononuclears, 344% (normal = 40% to 50%) 

Large mononuclears, 12.6% (normal = 10%) 

Polynuclear neutrophils, 51% (normal = 35% to 45%) 

Eosinophiles, .2% (normal = 1% to 5%) 

Myelocytes, 1 



The red corpuscles showed marked variation in size, shape 
and staining reaction. There was no tendency to large forms, 
but a slight tendency to oval forms. Sixteen normoblasts 
and nine megaloblasts were seen in counting five hundred 
white corpuscles. 

Diagnosis. The flattening of the head, the rosary, the 
retraction of the chest at the insertion of the diaphragm and 
the enlargement of the epiphyses at the wrists are signs of 
rickets, as is probably the delay in the eruption of the teeth. 
The general enlargement of the peripheral lymph nodes is 
merely a manifestation of a disturbance of the nutrition. 
The pallor and the changes in the blood show that she has an 
anemia. The presence of myelocytes, megaloblasts and such 
marked morphological changes in the red corpuscles would 
suggest, in an adult, pernicious anemia. In an infant, how- 



DISEASES OF THE BLOOD. 245 

ever, they are merely evidences of the tendency of the blood 
to revert to a younger type. The greater relative diminution 
in the percentage of hemoglobin than in the number of red 
corpuscles, 57% against about 70%, is characteristic of 
secondary anemia in infancy. (See Case 77.) The leucocy- 
tosis may or may not be directly connected with the anemia. 
It is not at all uncommon in secondary anemia in infancy, 
however, and is of no especial significance. The blood changes 
are, therefore, entirely consistent with those of secondary 
anemia. 

There is, in addition, a marked enlargement of the spleen. 
What is the connection, if any, between the rickets, the 
anemia and the enlargement of the spleen? Is any one of them 
the cause of the others, or are they all manifestations of some 
common cause? It is certain that the anemia and the splenic 
tumor could not have caused the rickets. Could the rickets 
have caused the anemia and splenic tumor? While it is con- 
ceivable that they might have, the chances are very much 
against it, because the study of large series of cases shows 
that there is no connection whatever between the severity of 
the rickets and that of the anemia and the size of the spleen, 
many babies showing marked rickets and no anemia, others 
mild rickets and severe anemia, and so on. In the same way, 
marked enlargement of the spleen is often found in connection 
with mild rickets and no enlargement of the spleen in some 
of the most marked cases. The study of other series of cases 
shows that there is no connection between the size of the 
spleen and the changes in the blood, very marked changes 
being present in the blood when the spleen is not enlarged, 
very slight when the spleen is much enlarged, and so on. 
It seems reasonable to conclude, therefore, that the rickets, 
the anemia and the enlargement of the spleen are all manifes- 
tations of some common cause. This cause is not hard to 
find. It is undoubtedly the disturbance of nutrition due to 
the prolonged use of too weak a food. 

The combination of marked changes in the blood and splenic 
tumor, as is present in this instance, has often been set aside 
as a special disease and described under various names, the 
most common of which is anemia infantum pseudoleukemica. 



246 CASE HISTORIES IN PEDIATRICS. 

The combination is always, however, as in this instance, 
accidental, and does not constitute a specific disease. The 
characteristics of the anemia are, as already shown, those of 
secondary anemia in infancy, and the enlargement of the 
spleen is merely a manifestation of the same disturbance of 
nutrition which is responsible for the anemia. It is better to 
speak of it, therefore, as Secondary Anemia with Splenic 
Tumor. 

Prognosis. The prognosis is perfectly good. When the 
underlying disturbance of nutrition is corrected the spleen 
will diminish rapidly in size and the anemia will quickly 
improve. The spleen will probably not be palpable after two 
or three months and the blood will be normal at least as soon. 

Treatment. The treatment is regulation of the diet to 
correct the disturbance of nutrition. The administration of 
iron will also hasten the return of the blood to normal. The 
following mixture is a suitable one for her: 

Fat. 4% 

Sugar. 7% 

Proteids. 2.50% 

Starch. 0.75% 

There is no indication for the addition of an alkali. Six 
feedings of five ounces will much more than supply the 
caloric needs indicated by her weight, but will probably be 
no more than are required when her age and surface area 
are taken into consideration. 

One or two tablespoonfuls of beef juice, once daily, given 
at the same time as one of her feedings, will aid in supplying 
the needed iron. It will be wiser, however, to give iron in 
addition. It may be given as the saccharated carbonate or 
in the form of ferratin. The dose of the former is three grains; 
that of the latter, two grains, three times daily. 



DISEASES OF THE BLOOD. 247 

CASE 80. Lester J. had always been well, but a little 
delicate. A slight enlargement of the cervical lymph nodes 
was noticed about the first of June. It had not increased 
materially up to July 10, when he came down with scarlet 
fever. The scarlet fever was of a very mild type and he was 
out of quarantine August 13. The swelling in the neck 
increased very rapidly after the onset of the scarlet fever. 
The temperature rose again August 20 and ran between 
103 F. and 104 F. Enlargement of the spleen was noticed 
for the first time August 23, but may have been present be- 
fore, as it had not been looked for until that time. The size 
of the liver was not investigated. The mouth and throat 
became sore August 26, and several spots of membrane ap- 
peared in the mouth. A culture showed no diphtheria bacilli.. 
He had had no disturbance of digestion, looseness of the 
bowels or hemorrhages, and had not lost weight, strength or 
color. He had not seemed seriously sick until a few days 
before he was seen in consultation, August 27, when six 
years old. 

Physical Examination. He was small, slight and flabby, 
but not very pale. There was an ulcerated area, the size of a 
dime, covered with false membrane, on the left side of the 
mouth. The whole throat was slightly reddened. The tonsils 
were moderately enlarged. The tongue was somewhat dry 
and slightly coated. There was no nasal discharge. There 
was a large mass of discrete, non-tender lymph nodes in the 
left side of the neck, which filled up the whole neck, extend- 
ing forward even with the chin and downward to the clavicle. 
There were numerous small lymph nodes in the right side of 
the neck. There was no dullness under the manubrium or 
in the middle of the back, and the bronchial voice sounds did 
not extend below the seventh cervical spine, showing that there 
was no considerable enlargement of the bronchial lymph 
nodes. There was no venous hum in the neck. The heart, 
lungs and abdomen were normal. The upper border of the 
liver flatness was at the upper border of the fifth rib (normal 
is in the fifth space). The lower border was palpable, running 
from just above the right anterior superior spine, through a 
point two thirds the distance from the ensiform to the navel, 



248 CASE HISTORIES IN PEDIATRICS. 

to the left costal border in the nipple line. The surface of the 
liver was hard and smooth, the edge rounded. The spleen 
was palpable, running out from the costal border between the 
left nipple and anterior axillary lines, downward and for- 
ward almost to the median line, backward to the left anterior 
superior spine and upward into the flank. The surface was 
smooth, the consistency hard, the edge rounded, the notch 
distinct. The extremities were normal. There was no spasm 
or paralysis. The knee-jerks were equal and normal. There 
were numerous lymph nodes, the size of marbles, in the axillae 
and groins, and one, the size of a walnut, on the occiput. 
The epitrochlear lymph nodes were not palpable. The 
mouth temperature was 104 F. 

The urine was high in color, extremely acid in reaction, and 
of a specific gravity of 1,032. It was loaded with urates, but 
contained no albumin or sugar. The sediment showed a few 
small round cells, but no casts. 



Blood. 




Hemoglobin, 


70% 


Red corpuscles, 


3,520,000 


White corpuscles, 


128,000 


Mononuclears (almost entirely lymphocytes), 


99-2% 


Polynuclear neutrophiles, 


•6% 


Myelocytes, 


.2% 



There was a very little variation in the size of the red 
corpuscles, but none in their shape or color. No nucleated 
cells were seen while counting five hundred white corpuscles. 

Diagnosis. Without the examination of the blood the 
diagnosis would lie between lymphatic leukemia and Hodg- 
kin's disease. The enlargement of the liver and the ulceration 
of the mouth would, however, make lymphatic leukemia the 
more probable. The examination of the blood proves con- 
clusively that the trouble is Lymphatic Leukemia. The 
enlargement of the lymph nodes preceded the attack of 
scarlet fever by six weeks. It is almost certain, therefore, 
that this was merely a coincidence and that it played no part 
in the etiology of the leukemia. 

Prognosis. The prognosis is absolutely hopeless. He will 
probably not live more than one or two weeks. 



DISEASES OF THE BLOOD. 249 

Treatment. There is nothing to be expected from treat- 
ment. Arsenic and iron should be tried, however, with the 
hope that they may alleviate the condition and perhaps pro- 
long life. The arsenic is best given in the form of Fowler's 
solution. It will be well to begin with three drops, three 
times a day, increasing the dose one drop daily until the 
physiological limit is reached. Other treatment must be 
symptomatic. 



25O CASE HISTORIES IN PEDIATRICS. 

CASE 81. Mary C, three years old, was the only child of 
healthy parents. There had been no deaths or miscarriages. 
She was born at full term after a normal labor, was normal 
at birth and weighed eight pounds. She was nursed for 
seven months and did very well. Since then she had taken 
milk well, but it had been very hard to induce her to take 
other food. She had, nevertheless, been very well. 

Seven weeks before she was seen in consultation she began 
to seem a little out of sorts and to lose color. The chief 
symptom had been anorexia and the greatest difficulty had 
been experienced in getting her to take anything, even milk. 
She had vomited occasionally, probably as the result of the 
forcing of food rather than of indigestion. There had been 
a tendency to constipation, which had been easily relieved 
by castoria. The movements had been well digested. Her 
only complaint was of being tired. She did not want to play 
with other children, but preferred to keep quiet or lie down. 
She had not lost weight but had steadily lost color. Purpuric 
spots had appeared on the legs a week previously. She had 
slept poorly and perspired freely. She had had no fever. 

Physical Examination. She was well developed and nour- 
ished, but very pale. Her flesh was firm. There was no 
edema. The tongue was clean, the mouth and throat normal. 
There was a venous hum in the neck. The heart was normal, 
except for a slight systolic murmur at the pulmonic area, 
which was not transmitted. The lungs were normal. The 
liver and spleen were not palpable. The extremities were 
normal. There was no spasm or paralysis. The knee-jerks 
were equal and normal. There was no enlargement of the 
peripheral lymph nodes. There were a dozen or more pur- 
puric spots, varying in size from that of a split pea to that of 
a dime, scattered over the arms and legs, there being more 
on the legs than on the arms. 

Blood. 



Hemoglobin, 


.25% 


Red corpuscles, 


2,560,000 


White corpuscles, 


15,400 


Lymphocytes, 


99% 


Polynuclear neutrophiles, 


1% 



DISEASES OF THE BLOOD. 25 1 

There was a little variation in the size and shape of the 
red corpuscles, but most of them were of normal size. There 
was moderate achromia, but no polychromatophilia. There 
was no stippling. One normoblast was seen for each one 
hundred leucocytes. No plasmodia or blood plates were 
seen. 

Diagnosis. The diagnosis lies between a rather severe 
anemia, secondary to an insufficient or improperly balanced 
diet over a long period, with lymphocytosis, and lymphatic 
leukemia in an aleukemic stage. The symptomatology is 
consistent with either diagnosis. The diminution in the 
hemoglobin and in the number of the red corpuscles, as well 
as the morphological changes in them, are consistent with 
either condition. A percentage of lymphocytes as high as 
ninety-nine per cent is practically unheard of outside of 
lymphatic leukemia and is of far more importance in differ- 
ential diagnosis than the comparatively slight increase in the 
total number of the white cells, because the number of white 
cells is often for a time but little increased in lymphatic leu- 
kemia. The absence of blood plates is of itself, moreover, 
sufficient to turn the scale in favor of leukemia, in which the 
blood plates are markedly diminished, while in secondary 
anemia they are normal or increased in number. The lymph 
nodes and spleen are usually, but not always, enlarged in 
lymphatic leukemia. The absence of such enlargement in 
this instance does not, therefore, rule it out. The diagnosis 
is, therefore, Lymphatic Leukemia. 

Prognosis. The prognosis is absolutely bad. She will 
probably not live more than one or two months. 

Treatment. She must, if possible, be made to take a more 
varied diet. If she will not take sufficient food, it must be 
given through a stomach tube, passed through the mouth. 
There is little to be expected from medicinal treatment. 
Arsenic and iron should be tried, however, with the hope that 
they may alleviate the condition and perhaps prolong life. 
The arsenic is best given in the form of Fowler's solution. It 
will be well to begin with two drops, three times daily, 
increasing the dose one drop daily until the physiological 
limit is reached. Other treatment must be symptomatic. 



252 CASE HISTORIES IN PEDIATRICS. 

CASE 82. Carl G. was the only child of healthy parents 
and was born at full term. His mother had had one mis- 
carriage at six months, probably as the result of albuminuria. 
He lived on a farm in the country and had always drunk the 
unsterilized milk from a herd of cows which had for many 
years been infected with tuberculosis. He had had measles 
and chicken-pox as a baby and an abscess in the neck at two 
years, which was opened and healed well. 

He began to be out of sorts about the first of January, 
when six and one-half years old. There were no very definite 
symptoms, however, so that a physician was not called until 
about the middle of March. He found that the boy was 
running an irregular temperature, which at times went as 
high as 1 03. 5 F., and that he had an enlarged liver and a 
very large spleen. The urine showed nothing abnormal. 
The leucocytes numbered 6,000. Typhoid fever was suspected, 
but a Widal test was negative. He then improved for a 
time in every way and probably had little or no fever, although 
his temperature was not taken. He was up and about, played 
out of doors and seemed much like himself, except that he 
was easily tired. 

The fever returned about the middle of August. The tem- 
perature was very irregular, most of the time being normal 
or subnormal, but reaching 103 F. or 103.5 F. f° r a time 
almost every day. Malaria was suspected, although there 
were no chills or sweating. Several examinations of the fresh 
blood failed, however, to show any plasmodia, and there was 
no change in the temperature when quinine was given. 
There had been no change in the size of the liver and spleen. 
The urine showed nothing abnormal. The red corpuscles 
numbered 3,700,000 and the white corpuscles, 6,000. He 
had lost some color. His appetite and digestion had been 
good throughout and he had not lost weight. He had had 
no cough, but several nosebleeds, one of them very severe. 
He was seen in consultation, August 29, when a little more 
than seven years old. 

Physical Examination. He was fairly developed and 
nourished, but moderately pale. He did not look especially 
sick. His tongue was clean and moist, his teeth poor. The 



DISEASES OF THE BLOOD. 253 

nose and throat were normal. There was no venous hum in 
the neck. The heart and lungs were normal. The abdomen 
was considerably enlarged, but there were no evidences of 
fluid and no masses were felt. The superficial abdominal 
veins were not enlarged. The upper border of the liver 
flatness was at the upper border of the fifth rib in the nipple 
line (normal is in fifth space) and at the upper border of 
the ninth rib in the scapular line (normal is at the tenth 
rib). The lower border of the liver was palpable, running 
out from the right flank, 4 cm. below the costal border in 
the right anterior axillary line, through a point two thirds 
the distance from the tip of the ensiform to the navel, and 
under the costal border in the left nipple line. The liver was 
not tender, its surface was smooth, its edge sharp. The 
spleen was palpable, running out from beneath the costal 
border in the left nipple line, downward and inward nearly 
to the navel, downward and outward to below the level of 
the left anterior superior spine, then backward into the 
flank, which it filled. It was firm, smooth and not tender. 
The edge was somewhat rounded, the notch distinct. The 
extremities were normal. There was no spasm or paralysis. 
The knee-jerks were equal and normal. There was no 
enlargement of the peripheral lymph nodes and no evidence 
of enlargement of the tracheo-bronchial lymph nodes. There 
w T as no edema. There was no eruption and no scars of old 
eruptions. 

The urine was normal in color, acid in reaction, of a specific 
gravity of 1,020, and contained neither albumin nor sugar. 
The sediment showed nothing abnormal. 

Blood. 

Hemoglobin, 90% 

Red corpuscles, 3,520,000 

White corpuscles, 5>7oo 

Mononuclears (the majority small), 60.0% 

Polynuclear neutrophiles, 38.7% 

Myelocytes, i-3% 

The red corpuscles showed no changes in size, shape or 
coloring, and no nucleated cells or plasmodia were seen. 
Diagnosis. The diagnosis lies between lymphatic leu- 



254 CASE HISTORIES IN PEDIATRICS. 

kemia in an aleukemic stage, Hodgkin's disease and that very 
indefinite class of cases known as splenic anemia or anemia 
with splenic tumor. Tuberculosis, which is suggested by 
the prolonged use of milk from a tuberculous herd, can be 
excluded by the absence of signs of tuberculosis elsewhere, 
the slight impairment of the general condition after six 
months, the fact that the liver and spleen are apparently 
alone involved and that the enlargement of these organs is 
regular. A tuberculin test would not be of much assistance. 
If negative, it would, of course, exclude tuberculosis, but, if 
positive, it would not prove that the enlargement of the liver 
and spleen and the fever are tubercular in origin. Syphilis 
can be ruled out on the good family history, the previous 
good health, the fever and the absence of all other signs of 
syphilis in the past or present. Cirrhosis of the liver is 
rendered very improbable by the absence of cause, ascites, 
jaundice and enlargement of the superficial abdominal veins, 
the fever and the relatively great enlargement of the spleen. 

Lymphatic leukemia in an aleukemic stage can be practi- 
cally eliminated on the duration of the illness, the low white 
count on several occasions (the aleukemic stage usually being 
a short one), the absence of morphological changes in the 
red cells and the marked enlargement of the liver and spleen 
without enlargement of the lymph nodes. 

The fever, the condition of the blood, the enlargement of 
the liver and spleen and the relatively slight impairment of 
the nutrition are all consistent with Hodgkin's disease. It 
is almost unheard of, however, to have so much enlargement 
of the liver and spleen without enlargement of either the 
superficial or deep lymph nodes. Hodgkin's disease can, 
therefore, be excluded. 

The most probable diagnosis is, therefore, splenic anemia, 
or better, Anemia with Splenic Tumor. This is, however, 
not a very satisfactory diagnosis because it does not describe 
a definite pathological entity, but is merely a term applied 
to a group of cases in which there is enlargement of the spleen 
and anemia, but of which the pathology and etiology are 
very varied. It is at present, however, impossible to classify 
them any more accurately. 



DISEASES OF THE BLOOD. 255 

Prognosis. The prognosis is very uncertain. He may 
gradually improve and grow up with a large liver and spleen, 
which do not cause any symptoms or inconvenience, or they 
may both finally return to their normal size. He may, on 
the other hand, fail rapidly and die in a few months or live 
on for some years and then die. The chances are that he 
will not live more than a year. 

Treatment. The treatment must, in the main, be hygienic 
and symptomatic. It will be well to try arsenic thoroughly. 
It is best given in the form of Fowler's solution. It will be 
well to begin with three drops, three times a day, increasing 
the dose one drop daily until the physiological limit is reached. 
It should then be continued, in doses somewhat below the 
physiological limit, for several months. If he does not im- 
prove, or continues to fail, splenectomy ought to be consid- 
ered, because, while it is a serious operation and if successful 
does not always relieve the symptoms, it sometimes results 
in a cure. 



SECTION XL 

DISEASES OF THE NERVOUS SYSTEM. 

CASE 83. Ronald P., six years old, was the only child of 
very nervous parents. His father was alcoholic, but there was 
no history of syphilis. His home surroundings were very 
exciting and he was under little control. He had an ungov- 
ernable temper and was in the habit of biting, fighting and 
swearing when opposed. He had had the croup every winter, 
but no other affections of the respiratory tract. His diet 
was a fair one for the country, and his appetite and digestion 
were good. He had had no other illnesses. 

Three months before he was seen in consultation he began 
to throw his arms up over his head in a peculiar manner, the 
motions always being the same. A diagnosis of chorea was 
made by his physician and he was given Fowler's solution. 
Soon after taking this he began to clear his throat constantly, 
while there was no diminution in the movements of his arms. 
More than nine drops of Fowler's solution a day caused 
edema of the eyelids, congestion of the conjunctivae and a 
nasal discharge. He had taken it fairly regularly in small 
doses, however, up to the time he was seen. He had begun 
to shrug his shoulders about six weeks before. The peculiar 
motions of the arms, the clearing of the throat and the 
shrugging of the shoulders all persisted. The movements 
and the clearing of the throat ceased during sleep. He did 
not seem sick in other ways. 

Physical Examination. He was fairly developed and 
nourished and of good color. He was very excitable and was 
constantly clearing his throat and shrugging his shoulders 
during the examination. He could keep still when he tried. 
The pupils were equal and reacted to light and accommoda- 
tion. There was no coryza and he kept his mouth shut. 
Examination with the ringer showed no adenoids. The throat 
was normal. The tongue was clean and was protruded 

257 



258 CASE HISTORIES IN PEDIAIRICS. 

without tremor. The heart, lungs and abdomen were normal. 
The liver and spleen were not palpable. The extremities 
were normal. There was no spasm or paralysis. The knee- 
jerks were equal and slightly diminished. Kernig's and 
Babinski's signs were absent. There was no ankle clonus. 
The cremasteric reflexes were normal, the abdominal lively. 
The genitals were normal. There was no enlargement of 
the peripheral lymph nodes. There was no eruption and no 
irritation of the skin. 

Diagnosis. The diagnosis lies betweeen chorea and habit 
spasms. The clearing of the throat is not at all like chorea, 
the motions are limited in number and always the same, he 
can control them to a considerable extent, and there is no 
tremor of the tongue. Chorea can, therefore, be excluded 
and a positive diagnosis of Habit Spasms made. These are 
especially likely to develop in children of neurotic parentage 
and living in exciting surroundings, as in this instance. 
There is usually some local cause for the development of 
the individual spasms, such as an uncomfortable hat, a 
badly fitting collar or a poorly adjusted suspender. No 
definite cause for the motions of the arms and the shrugging 
of the shoulders was made out in this boy. The irritation 
of the nose and throat caused by the arsenic was presumably 
the primary cause of the clearing of the throat; its continu- 
ance is due to the underlying neurotic condition. 

Prognosis. These habit spasms never lead to chorea. 
They are likely to persist for long periods, however, or to 
be replaced by others, because, even if the local cause can 
be found and removed and the individual spasm relieved, it 
is very difficult to get at the underlying trouble, that is, the 
inherited neurotic temperament. The prognosis is worse 
than usual in this instance, because the home surroundings 
are so bad and because he has not been controlled in the past. 

Treatment. The treatment of habit spasms can be divided 
into three parts: that directed to the removal of the local 
cause of the individual spasm, if it is still present; that of 
the individual spasm ; and that directed to the improvement 
of the underlying neurotic condition. Nothing was found 
in this instance to account for the peculiar motions of the 



DISEASES OF THE NERVOUS SYSTEM. 259 

arms or the shrugging of the shoulders. The local cause, 
whatever it was, must, therefore, have been accidentally 
remedied. The best treatment for the shrugging of the 
shoulders and the motions of the arms is to have him make 
these motions before a mirror for several minutes, several 
times daily. What is at present an involuntary act will 
come by practice under the control of the will again and hence 
be performed only voluntarily. The arsenic, wdiich was, by 
the irritation which it caused, presumably the original cause 
of the clearing of the throat, has already been stopped. It 
is possible, however, that some local irritation still persists. 
This can be treated by some mild alkaline or oily spray like 
the liquor antisepticus alkalinus of the Pharmacopeia, or 
the following mixture: 

Menthol, I gr. 

Camphor, i gr. 

Liquid albolene, i oz. 

The treatment of the underlying neurotic condition is a 
very difficult matter. It includes, in the first place, regula- 
tion of his home surroundings in general. It is probable that 
little can be done in this direction. His diet, exercise, amuse- 
ments and rest must all be carefully laid out. He must have 
much fresh air and ought not to go to school at present. 
Drugs will probably not be of much assistance, although 
the tincture of nux vomica in five-drop doses, three times 
daily, before meals, and eisenzucker or ferratin in five- 
grain doses, three times daily, after meals, may be of some 
assistance. 



260 CASE HISTORIES IN PEDIATRICS. 

CASE 84. Porter M., four years old, was the fourth child 
of healthy parents. He was born at full term after a normal 
delivery and w T as normal at birth. His father had had several 
convulsions when a child. One of his brothers, ten years old, 
was in an asylum for epileptics for convulsions which began 
after a fall out of bed at two years. 

He had always been perfectly well up to six months before, 
when, in common with his sister, he had an acute attack of 
fever and vomiting, apparently due to drinking milk from a 
sick cow. Both had convulsions at the onset of the illness. 
His sister had no more. ■ He was in bed four days and had 
several convulsions during that time. His next convulsion 
was two weeks after he was up and about. Since then he 
had had a great many convulsions, lasting from one to five 
minutes. His mother thought that he did not lose con- 
sciousness in them. He never frothed at the mouth, bit 
his tongue or passed urine or feces. He also had many very 
short attacks in w T hich he apparently lost consciousness 
momentarily, dropped things, stared for an. instant and so 
on, but never fell down. Various diets had been tried with- 
out effect. He was for some time on a strictly vegetable 
diet, at another had nothing but malted milk for a month, 
and at another only milk, bread and cookies. His appetite 
was good and he had no signs of indigestion except that 
he was ver> constipated. The movements at times con- 
tained mucus, but w^ere otherwise normal. He had been 
circumcised and had adenoids removed without any effect 
on the convulsions. His mental condition was perfectly 
normal. 

About six weeks before he was seen in consultation the 
convulsions became much more frequent and severe and 
bromide was begun. Since small doses had no effect on the 
convulsions, the dosage was increased until he w T as taking 
enormous amounts with the addition of chloral. Since 
taking the bromide he had become so stupid that he could 
not hold up his head or hold things in his hands, kept his 
mouth open and drooled constantly. His appetite had 
fallen off and he had lost considerable weight. The severe 
attacks were relieved by the bromide, but he continued to 



DISEASES OF THE NERVOUS SYSTEM. 26 1 

have the mild ones. The bromide had been diminished during 
the last week and he had begun to be more like himself. 

Physical Examination. He was fairly developed and 
nourished and moderately pale. He took very little notice 
of his surroundings, although at times he brightened up 
momentarily and appeared perfectly normal mentally. He 
held up his head with some difficulty and could hardly sit 
alone. He could walk with help, but very feebly and un- 
steadily. He kept his mouth open and drooled constantly. 
There was no spasm or paralysis of amy of the muscles con- 
trolled by the cranial nerves. The fundi of the eyes showed 
nothing abnormal. The ear-drums were normal. The tonsils 
were large, but not inflamed. The tongue was considerably 
coated. The heart, lungs and abdomen were normal. The 
lower border of the liver was just palpable in the nipple 
line. The spleen was not palpable. The extremities were 
normal. There was no spasm or paralysis. All his motions 
were, however, unsteady and feeble. The knee-jerks were 
equal and normal, as were the abdominal and cremasteric 
reflexes. Kernig's and Babinski's signs were absent. The 
sensation to touch and pain was slightly dulled. He was 
circumcised. There was no enlargement of the peripheral 
lymph nodes. 

The urine showed nothing abnormal. 

Diagnosis. The bromide intoxication obscures the diag- 
nosis to a certain extent. There is but little doubt, however, 
that the stupidity and muscular weakness are due to the bro- 
mide and not symptoms of any cerebral disease, The omis- 
sion of the bromide will quickly settle this point. The absence 
of spasm, paralysis, changes in the reflexes and of Kernig's 
and Babinski's signs, and the normal condition of the 
fundi, prove that there is no gross cerebral lesion. The 
diagnosis lies, therefore, between ''idiopathic" epilepsy and 
reflex convulsions, presumably from disturbance in the 
digestive tract, since all other causes of reflex convulsions 
are excluded by the physical examination. The family 
history is of but little aid, as the tendency to convulsions 
from slight causes, shown in the father and sister, balances 
the epilepsy in the brother. The onset of the convulsions 



262 CASE HISTORIES IN PEDIATRICS. 

with the onset of an acute disease is somewhat against 
epilepsy, but does not by any means exclude it, because the 
first convulsions may have caused some cerebral lesion which 
resulted in epilepsy, or the acute disease may have lighted 
up a latent epilepsy. The nature of the attacks, which, 
according to the parents, are not accompanied by an initial 
cry or loss of consciousness, is somewhat against epilepsy, 
but does not exclude it, because a cry is often lacking in 
epilepsy and because the parents may be wrong as to the 
retention of consciousness. In fact, they probably are, be- 
cause if he loses consciousness in the slight attacks he almost 
certainly does in the more severe ones. On the other hand, 
the symptoms of disturbance in the digestive tract are hardly 
severe enough to make it probable that there is sufficient 
intestinal irritation or toxic absorption from the intestines 
to cause so many and so severe convulsions. Regulation of 
the diet and of the bowels has had, moreover, no effect on 
the number or severity of the convulsions. The chances 
are, therefore, that the condition really is Epilepsy. The 
only way to settle the diagnosis positively, however, is by 
careful regulation of the diet, bowels and general routine 
for a considerable time. If the convulsions persist, the 
diagnosis of epilepsy will be confirmed; if they cease, it will 
have to be changed to reflex convulsions. 

Prognosis. The prognosis depends on the final diagnosis. 
If this is epilepsy, there is a possibility of recovery, but the 
chances are very much against it. The convulsions will, 
however, probably become much less frequent but more 
severe. 

Treatment. The bromide should be stopped for the 
present in order to determine positively as to his mental and 
physical condition. He should be put on a diet of milk and 
starches to diminish intestinal putrefaction and his bowels 
kept freely open, preferably with some mild saline, like 
phosphate of soda. There is no objection to adding fruit 
and green vegetables to the diet for their laxative action. 
He must, of course, be carefully watched to prevent him from 
injuring himself during the attacks. 



DISEASES OF THE NERVOUS SYSTEM. 263 

CASE 85. Mary B., two years old, was the second child 
of extremely neurotic parents. She had always been far 
ahead of her age in her mental development. She was not 
nursed but was fed during the first year on modified milk, 
prepared at home, and then on a very careful diet. She had 
always been very constipated and had had various laxatives, 
enemata and suppositories almost constantly since birth. 
Her digestion, except for occasional acute upsets, had been 
otherwise fairly good. She had had no other illnesses except 
two attacks of bronchitis and a mild attack of pyelitis. She 
sat up alone at eleven months and walked at twenty months. 
She cut her first tooth at ten months, but had eight when a 
year old. 

She began to have convulsions when a year old. She 
almost always had one or two, and often as many as half a 
dozen, daily. The longest interval between convulsions 
during the year had been ten days. They almost always 
came on when she was angry, frightened or in pain. A fit 
of crying almost always ended in a convulsion. She would 
often have one if she was refused anything which she wanted. 
A fall or a bump was usually followed by one. She often had 
one during defecation, if the movement was hard. She was 
seen in one, which came on as the result of a rectal examina- 
tion. She cried, held her breath and became a little blue. 
She then gave a short cry, stiffened out, raised her clenched 
hands before her face and then slowly dropped them. She 
was not cyanotic, breathed regularly during the attack, 
made no other movements, lost consciousness and passed 
both urine and feces. The attack did not last more than half 
a minute. She was dull and pale for several minutes after 
it. Her mother said that this was an unusually severe one 
and that many of them were merely slight " fainting spells." 
The attacks occurred more frequently when the bowels were 
not moving freely, when she was cutting teeth, when she 
was not kept free from excitement, and when she was below 
par physically. She had never had any definite attacks of 
laryngismus stridulus, and Trousseau's symptom and the 
facial phenomenon had been absent at repeated examinations. 

Physical Examination. She was small but fairly nourished. 



264 CASE HISTORIES IN PEDIATRICS. 

Her flesh was firm and her color good. Her mental develop- 
ment was nearer that of a child of three than of two years. 
The anterior fontanelle was not quite closed. There was no 
craniotabes. She had sixteen teeth. Her mouth and throat 
were normal and her tongue clean. There was no spasm or 
paralysis of any of the muscles controlled by the cranial 
nerves. There was a slight rosary. The heart, lungs and 
abdomen were normal. The liver was just palpable in the 
nipple line. The spleen was not palpable. The extremities 
were normal. There was no spasm or paralysis. The knee- 
jerks were equal and normal. Kernig's and Babinski's signs 
were absent, as were Trousseau's sign and the. facial phe- 
nomenon. There was no enlargement of the peripheral 
lymph nodes. 

The urine was pale in color, acid in reaction and of a specific 
gravity of 1,015. It containd neither albumin nor sugar. 
The sediment showed nothing abnormal. 

Diagnosis. The absence of Trousseau's symptom, the 
facial phenomenon and attacks of laryngismus stridulus 
shows that the convulsions are not manifestations of the 
spasmophilic diathesis (see Cases 53 and 88). The absence 
of spasm and paralysis, the normal condition of the reflexes, 
the absence of Kernig's and Babinski's signs and the normal 
mental development rule out any gross cerebral lesion. The 
diagnosis lies, therefore, between " idiopathic epilepsy " and 
reflex convulsions from slight causes in a child with an unu- 
sually irritable nervous organization. The character of the 
convulsions and their long continuance are in favor of epilepsy. 
The strongest point against it is the fact that the convulsions 
never occur without some definite cause. This fact, while 
it does not rule out epilepsy, is important enough to more 
than counterbalance the character and continuance of the 
convulsions and to make epilepsy very improbable. The 
chances are, therefore, against epilepsy and in favor of 
Reflex Convulsions. Time alone, however, can settle the 
diagnosis positively. If they persist after she grows older and 
can be better controlled, the diagnosis will have to be changed 
to epilepsy. 

Prognosis. The convulsions will probably gradually 



DISEASES OF THE NERVOUS SYSTEM. 265 

diminish in frequency and finally cease as she grows older 
and can be reasoned with and taught self-control: 

Treatment. The treatment consists in regulation of her 
diet and bowels, and in training her in self-control. This 
will, however, be very difficult because crossing her is very 
likely to bring on a convulsion. She must be made to obey 
and to lead a normal life even if the number of convulsions is 
temporarily increased, as in this way only can she be con- 
trolled. Quiet surroundings and freedom from excitement are 
especially important in this connection. There is no direct 
indication for medicinal treatment. Everything which will 
tend to improve her physical condition is, of course, of im- 
portance. The most minute details of her life must be looked 
into and regulated. 



266 CASE HISTORIES IN PEDIATRICS. 

CASE 86. Helen T.'s parents were feeble but not alco- 
holic or especially nervous. One other child was well. There 
had been no deaths or miscarriages. 

She was born at full term after a normal labor, and seemed 
normal at birth. She had always been fed on condensed 
milk and recently had had crackers in addition. She had 
never been ill, except for a mild attack of diarrhea a month 
before. She had always been backward, but her parents had 
not thought much of it until she was sixteen months old. 
She had never learned to sit up alone and could say but one 
or two words. She was usually quiet and good-natured, but 
moaned occasionally. She was seen when two years old. 

Physical Examination. She was fairly developed and 
nourished, but pale and flabby. Her expression was dull and 
stupid. She stared about without taking much notice, but 
could see and hear. She usually lay quietly, with the excep- 
tion of coarse movements of her arms and fingers. She 
apparently amused herself by making a peculiar sucking 
noise and frequently made grimaces by putting out her 
tongue and rolling up her eyes. Her cry was hoarse but she 
said nothing. Her head was of good shape. The fontanelles 
were closed. The circumference of the head was 45 cm. 
(normal is 48 cm.) ; that of the chest, 43 cm. (normal is 
51 cm.). Her hair was soft and fine. The palpebral openings 
were narrow and the eyes appeared deep-set. The outer 
canthi were slightly higher than the inner. The epicanthic 
folds were not marked. The pupils were equal and reacted 
to light. The nose was short and flat and wider than usual 
between the eyes. She had twelve teeth. Her tongue was 
somewhat enlarged, but moist and smooth. She kept it 
protruded beyond the lips most of the time. A moderate 
amount of adenoids was felt with the finger. The throat was 
otherwise normal. The neck was of normal length and there 
were no supraclavicular pads. The thyroid was of normal 
size. She was able to hold up her head, but not to sit alone. 
There was a marked curve of weakness. There was a slight 
rosary. The heart and lungs were normal. The abdomen 
was slightly enlarged, but otherwise normal. The liver and 
spleen were not palpable. The extremities were of normal 



DISEASES OF THE NERVOUS SYSTEM. 



267 



length, the distance from the anterior superior spine to the 
sole being forty-six per cent of the total length. The epiphyses 
at the ankles were slightly enlarged. The hands were of good 
shape, except that the little fingers curved in rather more 
than usual. She had no idea of standing up or what her legs 
were for. There was no spasm or paralysis. The knee-jerks 
were equal and normal. Kernig's sign was absent. There 




Helen T. Case 86. 



was no enlargement of the peripheral lymph nodes. The skin 
was normal. 

The urine was cloudy, straw-colored, acid in reaction, and 
contained neither albumin nor sugar. The sediment consisted 
of amorphous phosphates. 



Blood. 



Hemoglobin, 
Red corpuscles, 
White corpuscles, 



70% 

5,192,000 

12,400 



Diagnosis. This child is, of course, an idiot. The history 
and the fact that she sees rule out amaurotic idiocy. The 
normal size and shape of the head exclude hydrocephalic and 



268 CASE HISTORIES IN PEDIATRICS. 

microcephalic idiocy. The absence of spasm, paralysis and 
exaggerated reflexes shows that there is no gross cerebral 
lesion, either congenital or as the result of hemorrhage at 
birth. The enlargement and protrusion of the tongue and the 
expression of the face suggest cretinism to a certain extent. 
This can be excluded, however, on the fineness of the hair, 
the normal condition of the skin, the absence of supraclavicu- 
lar pads, the normal length of the neck and of the extremities 
and the normal shape of the hands and feet. There are many 
points about the physical examination which are in favor of 
the Mongolian type of idiocy. These are the hoarse cry, 
the narrow palpebral openings, the obliqueness of the eyes, 
the distance between the eyes, the short and flat nose, the 
enlargement of the tongue and the incurvation of the little 
fingers. The incurvation of the little fingers is so common, 
however, even in normal persons, that it is of little importance. 
It is true that the back of the head is of good shape, that the 
epicanthic folds are not marked, that the angle of the eyes 
is but very little increased and that the tongue is not dry and 
fissured. Marked changes in the tongue almost never develop 
as early as two years, however, and the head is not always 
flattened anteroposteriorly in Mongolian idiocy. The angle 
of the eyes and the development of the epicanthic folds are 
merely questions of degree. The diagnosis of Mongolian 
Idiocy is, therefore, justified. 

Prognosis. Mongolian idiots are extremely susceptible to 
infection and resist disease very badly. She will probably, 
therefore, not live many years. There is no prospect that she 
will become a useful member of society or able to support 
herself. She will probably be able to walk and can probably 
be taught to feed herself and be cleanly in her habits. Little 
more than this can be expected. 

Treatment. She should be placed in some institution for 
the feeble-minded, because children are better taught and 
better cared for in such institutions than at home and be- 
cause, when in an institution, they do not serve as bad 
examples to other children. 



DISEASES OF THE NERVOUS SYSTEM. 269 

CASE 87. Joseph C. was the first child of healthy Jewish 
parents. There had been no miscarriages. He was born at 
full term after a normal labor and was normal at birth, 
although very small. He was breast-fed entirely until he 
was eight and one-half months old, after which he was ration- 
ally fed. His digestion had always been good. He " acted 
just like any other baby " until he was three or four months 
old, smiled, took things in his hands, was interested in his 
surroundings and kicked out with his legs. He had not 
learned to hold up his head, however. He then ceased to 
develop mentally and soon began to deteriorate, so that 
when he was eight months old his parents were sure that he 
was " not bright." He became dull and stupid, did not notice, 
would not hold things in his hands and seldom moved. 
Rigidity of the extremities developed when he was fourteen 
months old, and twitching of the face when he was seventeen 
months old. He began to have convulsions a few days before 
he was seen, when eighteen months old. He had taken his 
food well up to a few days before, when he began to have 
difficulty in swallowing. 

Physical Examination. He was fairly developed and nour- 
ished, but markedly pale. His head was of good shape and of 
normal size. The anterior fontanelle was 3 cm. in diameter 
and slightly depressed. There was no craniotabes. He was 
unable to hold up his head, which rolled limply from side to 
side. He heard but -could not see. The pupils were equal 
and reacted to light. His expression was vacant. He kept 
his mouth open and drooled constantly. He had six teeth. 
The throat was normal and there were no adenoids. He could 
not sit up. The back showed a marked curve of weakness. 
There was a moderate rosary. The heart, lungs and abdomen 
were normal. The liver was palpable 1 cm. below the costal 
border in the nipple line. The spleen was not palpable. He 
lay on his back and seldom moved, except to turn his head. 
He held his hands flexed at the wrists, with the fingers 
partially flexed. There was, however, very little resistance 
to passive extension of the fingers and hands. The arms 
dropped naccidly when lifted up. He usually held his legs 
and feet extended. There was at times marked opposition to 



270 CASE HISTORIES IN PEDIATRICS. 

passive motions; at others, the legs were perfectly flaccid. 
The knee-jerks were usually absent; when present, they 
were very feeble. The cremasteric and abdominal reflexes 
were present. There was no ankle clonus. Kernig's and 
Babinski's signs were absent. Sensation to both touch and 
pain was present. There was a slight general enlargement of 
the peripheral lymph nodes. The rectal temperature was 
99 F., the pulse no, the respiration 30. He weighed seven- 
teen and one-half pounds. 

The urine was high in color, acid in reaction and of a specific 
gravity of 1,024. It contained neither albumin nor sugar. 
The sediment showed an excess of urates, but no cells or 
casts. 




Joseph C. Case 87. 



Diagnosis. This boy is undoubtedly an idiot. His race, 
the normal condition at birth, the normal development for 
some months followed by progressive physical and mental 
deterioration, taken together with the general flaccidity and 
the blindness, form a combination so characteristic of Amau- 
rotic Idiocy that a positive diagnosis of this condition is 
justified without further examination. There is no other 
condition which shows just this combination of history and 
physical signs. The diagnosis should, however, be verified 
by an examination of the fundi which in this disease present 
a picture which is absolutely pathognomonic. This is a dark, 
reddish-brown, circular spot occupying the site of the macula 
lutea and surrounded by a whitish zone about twice the di- 



DISEASES OF THE NERVOUS SYSTEM. 27 1 

ameter of the optic disk. The eyes of this boy were examined 
and the characteristic picture found, thus verifying the 
diagnosis. 

Prognosis. The prognosis is absolutely hopeless. If he is 
not fed with a tube, he will quickly starve to death. If he is 
fed with a tube, he may live for many months. Sooner or 
later, however, he will die of bronchopneumonia or some other 
intercurrent disease. 

Treatment. There is no treatment for this disease. He 
must be fed with a stomach tube and taken care of until he 
dies. 



272 CASE HISTORIES IN PEDIATRICS. 

CASE 88. Jacob A. was the child of healthy parents- 
One other child was well, two had died of " summer com- 
plaint " and three of diphtheria. There had been no mis- 
carriages. 

He was fed from birth on a mixture of three parts of whole 
milk and one of water. When five months old he was given 
tea and crackers, and probably other things also, in addition. 
He had always done well, had not vomited and had had nor- 
mal movements. He began to cry almost constantly October 
20. Swelling of the arms and legs appeared at the same time. 
He was seen October 22, when ten months old. 

Physical Examination. He was well developed and nour- 
ished, but rather pale. He was perfectly conscious. The 
parietal and frontal eminences were moderately enlarged, and 
the head was somewhat flattened on top. The anterior fon- 
tanelle was 4 cm . in diameter and level. The pupils were 
equal and reacted to light. There was no craniotabes. He 
had two teeth. The gums, mouth and throat were normal. 
The tongue was clean. The ear-drums were normal. There 
was a moderate rosary. The heart and lungs were normal. 
The level of the abdomen was somewhat below that of the 
thorax, but nothing abnormal was detected in it. The liver 
was palpable 2 cm. below the costal border in the nipple line. 
The spleen was not palpable. The epiphyses at the wrists 
were slightly enlarged. There was a rather tense swelling of 
the feet and legs half-way to the knees, and of the hands and 
lower halves of the forearms. This swelling was not hot, 
tender or red. It did not pit on pressure. He held his arms 
partly flexed at the elbows and at the wrists. The hands were 
turned a little to the ulnar side. The fingers and thumbs were 
flexed sharply at the metacarpo-phalangeal joints and ex- 
tended at the phalangeal joints, the thumb being inside the 
fingers. The legs were held partially flexed at the knees and 
partially extended at the ankles, with flexion of the toes at 
the metatarso-phalangeal and extension at the phalangeal 
joints. Any attempt to overcome the spasm in the arms and 
legs caused much pain. The knee-jerks could not be tested 
because of the spasm. Kernig's sign was absent. The facial 
phenomenon was absent. Trousseau's symptom could not 



DISEASES OF THE NERVOUS SYSTEM. 273 

be tested because of the spasm. There was a slight general 
enlargement of the peripheral lymph nodes. The rectal 
temperature was ioi° F., the pulse no, the respiration 40. 
A few minutes after the examination he became entirely 
relaxed. The spasm returned again, however, in a short 
time. 

The urine was pale, clear, acid in reaction, of a specific 
gravity of 1,010, and contained neither albumin nor sugar. 

Diagnosis. Tetanus can be ruled out on the absence of 
trismus and the characteristic position of the extremities. 
Meningitis can be excluded on the normal mental state, the 
level fontanelle, the absence of involvement of the cranial 
nerves and of rigidity of the neck and the characteristic 
position of the extremities. The age of the baby, the good 
general condition, the intermittence of the paroxysms, the 
pain in association with them and the swelling of the extremi- 
ties are all characteristic of tetany. The position of the 
extremities during the spasm is pathognomonic of Tetany 
and makes the diagnosis positive. The swelling of the extrem- 
ities is undoubtedly nervous in origin and belongs in the class 
of the angioneurotic edemas. The enlargement of the frontal 
and parietal eminences, the flattening of the top of the head, 
the rosary and the enlargement of the epiphyses at the wrists 
are signs of rickets, as is probably the delayed dentition. 

Tetany is not properly a disease but merely a manifestation 
of the spasmophilic diathesis. In this condition there is a 
marked increase in the nervous excitability, which shows 
itself in various ways, the most characteristic manifestations 
being laryngismus stridulus, tetany and convulsions. The 
spasmophilic diathesis is almost certainly due to some dis- 
turbance in the metabolism of calcium. It is uncertain 
whether this disturbance is or is not due to parathyroid 
insufficiency. There is in all probability a deficiency of cal- 
cium salts in the blood in the spasmophilic diathesis. His 
diet, which has been largely made up of cow's milk has never 
been deficient in calcium. The calcium in cow's milk is, how- 
ever, not nearly as well utilized as that in human milk, so 
that he may well not have absorbed a sufficient amount. 
The rickets is, therefore, merely another manifestation of 



274 CASE HISTORIES IN PEDIATRICS. 

disturbance of nutrition and not the cause of the paroxysmal 
contractions. 

Prognosis. The prognosis depends very largely on whether 
or not he can get the best treatment. If he can, the paroxysms 
will quickly cease. If he cannot, they will probably continue 
and other manifestations of the spasmophilic diathesis are 
very likely to develop. There is no danger of death in a 
paroxysm of tetany, but he may die in an attack of laryngis- 
mus stridulus or during a convulsion. 

Treatment. No treatment is necessary for the paroxysms 
unless they are more severe than at present. A bath at i io° F. 
is the best treatment. If the attacks become more severe, they 
can be controlled to a certain extent by bromide of sodium or 
potassium, in doses of from three to five grains, in an aqueous 
solution, given three or four times daily. The attacks will be 
less likely to develop if he is kept quiet and not disturbed. 

The treatment of the spasmophilic diathesis consists in 
regulation of the diet. Human milk always quickly relieves 
this condition. A purely carbohydrate diet relieves it, but 
much less promptly and is, moreover, unsuitable for a baby 
of this age. A return to cow's milk in any form, at any rate 
until a considerable time has elapsed, almost invariably 
causes a return of the symptoms. The only rational food for 
this baby is, therefore, human milk. If he cannot get it, he 
must be given a starch and sugar solution for as long a time as 
is possible, due regard being paid to his general condition, and 
then gradually worked on to some modification of cow's milk. 

It is possible that the administration of some of the cal- 
cium salts, like the lactate, might do good, but the indications 
are so doubtful and the results to be expected so slight com- 
pared to those obtained with human milk that they are hardly 
worthy of consideration. Parathyroid extract, in doses of 
one fifteenth of a grain, three times a day, would seem a more 
rational treatment, but has not been used enough to prove 
whether or not it is of any value. 



DISEASES OF THE NERVOUS SYSTEM. 2/5 

CASE 89. Baby T. was born at full term after a normal 
first pregnancy. The membranes ruptured January 1 1 and 
much liquor amnii drained away. Labor began the afternoon 
of January 12. The pains were hard, but very little progress 
was made. He was finally delivered by high forceps, after a 
manual dilatation, at 3 a.m., January 13. The operation was 
an easy one and did not take over an hour. The head was 
considerably compressed at birth but the fontanelles did not 
bulge. He weighed six and one-half pounds and seemed all 
right in every way. He cried normally and passed both urine 
and feces. He was not put to the breast but took water well. 

He suddenly stopped breathing and became deeply cya- 
notic at 8 p.m., January 13, seventeen hours after birth. He 
was brought around by artificial respiration, but had another 
similar attack about 9 p.m., which also required artificial 
respiration. He had breathed quietly and normally since 
then, but had not moved much and had not opened his eyes. 
A little twitching of the face was noticed during the morning 
of the 14th, and during the afternoon he moved his left arm 
constantly, but had no rigidity or convulsions. He took a 
little sugar and water during the day and passed both urine 
and feces. He became more stupid during the evening and 
could not be made to swallow. The pulse gradually fell 
during the day from 160 to 120. The rectal temperature 
varied between 99 F. and 99. 5 F. He was seen in consulta- 
tion at 10.30 p.m., January 14. 

Physical Examination. He was well developed and nour- 
ished, and of good color. He could not be roused or made to 
move. His neck w T as flaccid. The head was of good shape 
and of normal size. The anterior fontanelle w r as 3 cm. and 
the posterior fontanelle 2 cm. in diameter. Both bulged a 
little. The sagittal and coronal sutures were 1 J cm. wide and 
a little full; the other sutures were closed. The axes of the 
eyes were parallel. The pupils were a little smaller than a 
pinhead and did not react to light. A little dried blood was 
seen high up in the nostrils. The mouth and throat were 
normal. There was no facial paralysis and no marks of the 
forceps. The heart, lungs and abdomen were normal. The 
cord was healthy. The liver was palpable 1 cm. below the 



276 CASE HISTORIES IN PEDIATRICS. 

costal border in the nipple line. The spleen was not palpable. 
The arms were held slightly flexed at the elbows and the 
hands were clenched. The spasm was, however, very easily 
overcome. There was no spasm of the legs. The knee-jerks 
were not obtained. There was no Kernig's sign. The rectal 
temperature was 99. 5 F., the pulse 140, the respiration 24. 

Diagnosis. The diagnosis lies between some cerebral 
lesion, intestinal toxemia and sepsis. The facts that he has 
had no food, that his bowels have moved freely and that his 
temperature is practically normal are sufficient, in connection 
with the positive signs of cerebral trouble, to exclude intes- 
tinal toxemia. The normal condition of the cord, the normal 
temperature and the absence of any local manifestations of 
sepsis rule out sepsis. 

The age, lack of exposure and normal temperature exclude 
meningitis. The bulging of the fontanelles and sutures 
shows positively that there is an increase in the cerebral 
pressure. This was not present at birth. An internal hydro- 
cephalus could hardly have developed in seventeen hours. 
Serous meningitis does not develop without a cause and is 
usually accompanied by fever. The only reasonable ex- 
planation for the increased cerebral pressure is, therefore, a 
hemorrhage. The gradual development of the symptoms of 
increased cerebral pressure is perfectly consistent with a slow 
capillary oozing, which is the usual form of hemorrhage occur- 
ring at or soon after birth. The presence of blood high up in 
the nostrils is almost pathognomonic of cerebral hemorhage, 
the blood coming through the cribriform plate. The diag- 
nosis of Cerebral Hemorrhage is, therefore, justified. The 
diagnosis is so certain that it hardly seems necessary to do a 
lumbar puncture to confirm it. The spinal fluid does not 
always contain blood, moreover, when there is a cerebral 
hemorrhage, and the presence of blood does not always indi- 
cate cerebral hemorrhage, because it may be due to the wound- 
ing of some vessel during the puncture. The fact that the 
involuntary motions were confined to the left arm suggests 
that the hemorrhage is greater on the right than on the left 
side of the brain. This point is not of much importance, 
however, because, owing to the imperfect development of 



DISEASES OF THE NERVOUS SYSTEM. 277 

the cortical centers and the general nervous excitability at 
this age, no very definite conclusions can be drawn from what 
would be important localizing symptoms in an older child or 
an adult. 

Prognosis. He is almost certain to die if he is not operated 
upon. If he does not die, he will surely be paralyzed and 
probably feeble-minded. He will probably die during or soon 
after the operation. If he does not, he may still be paralyzed, 
but the paralysis w T ill be less extensive than it will be if he is 
not operated upon. There is a reasonable chance, however, 
that the operation will relieve the symptoms and that he will 
develop normally. 

Treatment. He should be operated on immediately. 
Delay will mean still further hemorrhage and more pressure 
on and damage to the brain. 



278 CASE HISTORIES IN PEDIATRICS. 

CASE 90. Elsie L., two and one-fourth years old, was 
the first child of healthy parents. There had been no mis- 
carriages. She was born after a very difficult instrumental 
vertex delivery at the end of a long labor and was almost dead 
at birth. She was not nursed, as she was too weak to take 
the breast. She did not thrive during infancy, but since then 
her general condition had been good. She had had no con- 
vulsions. She sat up alone at nine months and cut her first 
tooth at a year. She began to stand at sixteen months, but 
did not begin to walk at all until she was twenty-six months 
old. Her gait was then noticed to be very peculiar. She was 
brought because she did not walk well. She used her hands 
well, talked early and was bright mentally. She controlled 
the sphincters of the bladder and anus. 

Physical Examination. She was well developed and nour- 
ished and of good color. Her tongue was clean and her mouth 
and throat normal. There was no rosary. The heart, lungs 
and abdomen were normal. The liver and spleen were not 
palpable. She talked well for a child of her age and seemed 
bright. There was no spasm or paralysis of any of the muscles 
supplied by the cranial nerves. There was no deformity of 
the spine, and it was normally flexible. There was no paraly- 
sis or spasm of the arms, and the reflexes of the arms were 
normal. She stood with her knees close together, her body 
flexed on the thighs, the knees partially flexed and the heels 
a little off the ground. When she walked the knees rubbed 
together and one leg crossed in front of the other. When 
lying down the legs could be straightened on the thighs and 
the feet brought to a right angle, but with some little diffi- 
culty. Separation of the legs was resisted and was impossible 
to more than a moderate extent. There was decided resist- 
ance to hyperextension of the thighs. The knee-jerks were 
equal, but much exaggerated. There was no ankle clonus. 
The sensation was normal. The legs were warm, of good 
color and not wasted. Kernig's sign was absent. Babinski's 
phenomenon was present on both sides. There was no en- 
largement of the peripheral lymph nodes. 

Diagnosis. This little girl has a paraplegia with spasm. 
The spasm, exaggeration of the reflexes and normal sensation 



DISEASES OF THE NERVOUS SYSTEM. 279 

rule out any lesion of the peripheral nerves. The spasm, 
exaggeration of the reflexes and absence of wasting rule out a 
lesion of the anterior horns, such as occurs in anterior polio- 
myelitis. Transverse myelitis, except from disease of the 
spine, almost never occurs at this age. There is no deformity 
of the spine in this instance and it is normally flexible. Trans- 
verse myelitis from other causes can be excluded on its rarity 
at this age and the absence of loss of control of the sphincters 
and of disturbance of sensation. The lesion must, therefore, 
be in the brain. It is hard to conceive of a lesion anywhere 
in the brain which would cause a spastic paraplegia without 
other symptoms, except in the cortex. A lesion of the cortex 
in the region of the upper portion of the post-central convolu- 
tion on both sides of the longitudinal fissure would cause just 
such a combination. Such a lesion in an infant is usually a 
congenital defect or the result of a subdural hemorrhage at 
birth. The long, hard labor, which is the usual cause of such 
hemorrhages at birth, and her feeble condition after birth, 
make it almost certain that in this instance the lesion is due 
to a hemorrhage at birth. The diagnosis of Cerebral 
Paralysis resulting from a subdural hemorrhage at birth is, 
therefore, justified. 

Prognosis. There will be no extension of the paralysis and 
her mental development will be normal. There will be no 
spontaneous improvement in the condition of the legs. Much 
improvement in her walking can be expected, however, 
from suitable operations and apparatus. 

Treatment. Electricity and massage are useless in this 
condition because there is no disturbance of the nutrition of 
the muscles. It is probable that passive motions, if thor- 
oughly carried out, will prevent further contractures, but it is 
very doubtful if they will diminish those now present. Proper 
operative procedures, perhaps followed by the application of 
apparatus, ought to improve the position of her legs and make 
walking much easier. Resection of the posterior nerve roots, 
recently recommended for the relief of this condition, has not 
as yet been tried out thoroughly enough to justify its use, 
except as a last resort. She should be placed in the hands of 
an orthopedic surgeon for treatment. 



280 CASE HISTORIES IN PEDIATRICS. 

CASE 91. Robert K., two and three-fourths years old, 
was the child of healthy parents. One brother was alive and 
well, another had died at birth. There had been no mis- 
carriages. There was no tuberculosis in the family and there 
had been no known exposure to tuberculosis. He was born 
at full term after a normal labor and was normal at birth. He 
was nursed for eleven months. He had always been well, 
except for measles a year before and frequent colds with 
bronchitis. 

He fell down stairs, striking his head, early in the morning 
of August 3. He was apparently not hurt and appeared well 
all day. He began to vomit during the morning of August 4 
and continued to vomit, at intervals of about an hour, until 
3 a.m., August 5. He did not vomit again. There had been 
no known indiscretion in diet and the bowels were open. He 
was delirious in the early morning. He was admitted to the 
Children's Hospital at 2 p.m., August 5. 

Physical Examination. He was well developed and nour- 
ished and of good color. He was restless and irrational but, 
when roused, noticed a little. There was no rigidity of the 
neck and no neck sign. The pupils were equal and reacted to 
light. The tongue was fairly clean. The throat, heart, 
lungs and abdomen were normal. The liver and spleen were 
not palpable. There was no spasm or paralysis. The knee- 
jerks were equal and normal. Kernig's and Babinski's signs 
were absent. There was no ankle clonus. The rectal tem- 
perature was 99. 8° F., the pulse 120, the respiration 36. 

The urine was light yellow in color, clear, acid in reaction 
and contained no albumin, sugar or acetone. The sediment 
contained a few epithelial cells and crystals of uric acid. 

The fluid obtained by lumbar puncture was under con- 
siderable pressure. It ran clear at first, but the last of it was 
somewhat bloodstained. No fibrin clot formed in twenty- 
four hours. It contained 360 cells to the cubic millimeter, 
a part of which were undoubtedly due to the admixture of 
blood. The differential count of these cells, which showed 
90% of mononuclear to 10% of polynuclear, shows that 
only a few of them came from the blood, because, if many 
of them had come from the blood, the number of polynuclear 



DISEASES OF THE NERVOUS SYSTEM. 



281 



cells would have at least equaled that of the mononuclear. 
No tubercle bacilli or other organisms were seen on a routine 
examination, and cultures were sterile. 

He passed a very restless night and at times was quite 
noisy, requiring morphia to keep him quiet. He was quiet 



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Fig. 



Chart of Robert K. Case 91. 



and drowsy the morning of August 6. There was no rigidity 
of the neck or neck sign. The pupils were equal and reacted 
to light. The knee-jerks were equal and lively, the abdomi- 
nal and cremasteric reflexes normal. There was no Kernig's 
sign and no ankle clonus. 

He was quiet August 7. There was slight rigidity of the 
neck. The pupils were equal and reacted to light. The 



282 CASE HISTORIES IN PEDIATRICS. 

knee-jerks were present and equal, but sluggish. There was 
a suggestion of Kernig's sign on the left but none on the right. 
Babinski's phenomenon was absent. 

He recognized and spoke to his parents and remembered 
the names of friends and relatives August 8. He noticed 
more and was afraid of the light used to test the reaction of 
the pupils. They were equal and reacted to light. There 
was no rigidity of the neck, and no neck sign. There was 
no spasm or paralysis. The knee-jerks were equal and 
normal. The abdominal and cremasteric reflexes were not 
obtained. Kernig's and Babinski's signs were absent. 
Sensation to touch and pain was normal. 

The white blood count was 10,100. 

Another lumbar puncture was done. The fluid was clear 
and contained 480 cells to the cubic millimeter, 97% of 
which were small mononuclear. Many of the cells were 
degenerated. No organisms were seen in a routine exami- 
nation, and cultures were sterile. 

He was seen at 10 a.m., August 8. 

Diagnosis. The positive findings in the cerebrospinal 
fluid show that the trouble is located in the central nervous 
system (see Case 38 for description of the normal cerebro- 
spinal fluid and of the fluid in meningitis). They exclude 
all forms of meningitis except the tubercular, but are also 
consistent with acute poliomyelo-encephalitis, in the acute 
stage of which the cerebrospinal fluid contains a considerable 
excess of cells, largely small mononuclear. The diagnosis 
lies, therefore, between tubercular meningitis and acute 
poliomyelo-encephalitis. If it is poliomyelo-encephalitis, 
the stress of the disease has fallen in this instance, of course, 
on the cerebrum, and it can be spoken of as an encephalitis. 

The absence of a family history of, or of exposure to, 
tuberculosis does not rule out tubercular meningitis; the 
history of an attack of measles in the past is a small point 
in its favor. The acuteness of the onset is somewhat in 
favor of encephalitis, but is not inconsistent with tubercular 
meningitis. The fall was probably purely a coincidence, 
but, in any case, is of no assistance in differential diagnosis 
as it might predispose to the development of either condi- 



DISEASES OF THE NERVOUS SYSTEM. 283 

tion. There is nothing about the symptomatology which 
is inconsistent with either condition, although the absence 
of the neck sign and the slightness of the changes in the 
reflexes and of the rigidity of the neck are somewhat against 
tubercular meningitis. The improvement in the symptoms 
and the drop in the temperature, while they suggest the 
beginning of convalescence from encephalitis, do not by 
any means exclude tubercular meningitis, because remissions 
are characteristic of this disease. The absence of leuco- 
cytosis is common to both diseases. The absence of a 
fibrin clot in the cerebrospinal fluid counts against tuber- 
cular meningitis; the absence of tubercle bacilli does not, 
because they are not found in more than ten per cent of the 
cases, if the examination is merely a routine one. A positive 
diagnosis is, therefore, impossible. The weight of the 
evidence, is, however, somewhat in favor of Encephalitis, 
sufficiently so to justify it as a provisional diagnosis. Time 
alone can decide whether or not it is correct. 

Prognosis. If the diagnosis of encephalitis is correct, 
the prognosis is very good. He will almost certainly recover 
entirely and be left without sequelae, either mental or 
physical. 

Treatment. The treatment can only be symptomatic. 
Nothing can be done in any way to modify the course of 
the encephalitis. 



284 CASE HISTORIES IN PEDIATRICS. 

CASE 92. Fred C, seven and one-half years old, had 
always been well except for measles and whooping-cough 
some years before. He had been spending the summer in a 
locality within twenty miles of which there had been several 
cases of infantile paralysis during the past few weeks. 

He complained of headache the afternoon of September 7. 
He vomited and was somewhat feverish the next morning, 
but went in bathing that noon as usual. He complained 
in the evening that his throat felt a little full. He was given 
a laxative that night and had a good movement the morning 
of the 9th. He was brought home that day by train, a 
journey of about one hundred and twenty-five miles. He 
took a little milk and ate several crackers on the way. He 
walked out of the station to his automobile without diffi- 
culty. He undressed himself and ate a little supper, although 
he complained that it was hard for him to swallow. He was 
seen by his physician in the early evening. The physical 
examination, including the throat, showing nothing abnormal. 
His mouth temperature was 103 F., his pulse 115, and rather 
feeble. He collapsed about midnight and was seen again 
soon after by his physician. He was then slightly cyanotic. 
His pulse was very feeble and his respiration rapid. He was 
unable to swallow anything, not even his saliva. He was 
given an enema of hot milk and brandy and soon rallied. 
His color continued bad and his respiration rapid, however, 
and he was unable to swallow. He was seen in consultation 
at 7.30 a.m., September 10. 

Physical Examination. He was well developed and 
nourished and perfectly clear mentally. His face and 
extremities were a little dusky. There was no rigidity of 
the neck. He could move his head, but could not turn 
himself in bed. The pupils were equal and reacted to light. 
There was no paralysis of the eye muscles and no facial 
paralysis. His respiration was rapid but not noisy. He 
was coughing constantly but feebly, and was all the time 
trying, but usually unsuccessfully, to spit up bloody, frothy 
mucus. He could stick out his tongue. There was no 
paralysis of the soft palate. The throat was normal to inspec- 
tion and palpation. He could speak a word or two at a time 



DISEASES OF THE NERVOUS SYSTEM. 285 

distinctly. Respiration was entirely diaphragmatic. There 
was no movement of the chest wall, and the accessory mus- 
cles of respiration were not acting. There was no retraction 
of the suprasternal, supraclavicular or intercostal spaces. 
The respiratory sound was feeble, alike on both sides and 
normal in character. No rales were heard in front; the 
backs were not examined. The cardiac area was normal, 
the action a little irregular, the rate 124, the first sound 
of fair strength, and there were no murmurs. The abdomen 
was normal. The liver and spleen were not palpable. He 
could move his arms, but the movements were feeble. The 
abdominal and cremasteric reflexes were present. The legs 
were not examined. 

Diagnosis. The normal condition of the throat, the clear 
voice, the quiet respiration and the absence of retraction 
rule out all forms of obstruction of the air passages. There 
is no disease of the lungs which causes bilateral immobility of 
the chest. Edema of the lungs from cardiac failure is sug- 
gested by the bloody, frothy expectoration, but is excluded 
by the normal size and fair strength of the heart and the 
absence of rales. The only possible explanation of the symp- 
toms is paralysis of the muscles of respiration. This explana- 
tion is justified by the physical examination. There is also 
a paresis of the muscles of the arms and trunk. The diffi- 
culty in deglutition and the irregularity of the pulse make 
it probable that the pneumogastric nerve is also involved. 
The only disease of the nervous system which will explain 
the sudden appearance of this combination of symptoms is 
acute poliomyelo-encephalitis, commonly known as Infan- 
tile Paralysis. 

Prognosis. The prognosis is absolutely hopeless. He will 
probably live but a few hours. 

Treatment. There is no treatment which can do more 
than perhaps delay the fatal outcome a few hours. Oxygen 
must be given freely. Strychnia and caffein-sodium ben- 
zoate or salicylate may be given subcutaneously. The 
administration of morphia subcutaneously is justifiable, 
if he is very uncomfortable. 



286 CASE HISTORIES IN PEDIATRICS. 

CASE 93. John P., three years old, was the child of 
healthy parents and had always been well and strong. He 
had had a slight disturbance of the digestion August 20, 
which had yielded promptly to catharsis and regulation of 
the diet. He was restless and a little feverish during the 
evening of August 28, was given a large dose of castor oil by 
his mother and had several large, well-digested movements 
from it. It was discovered the next morning that he could 
not use his legs properly. He could move them in all direc- 
tions, but the movements were feeble. The rectal tempera- 
ture that morning was 101 F. There was no increase in the 
weakness of the legs during the day and he slept all that 
night. The loss of power was much more marked, however, 
the morning of the 30th. He complained of pain in his 
feet for the first time that morning. There was no disturb- 
ance of defecation or micturition. He had had no other 
symptoms. He was seen in consultation August 30 at 
10.30 A.M. 

Physical Examination. He was well developed and 
nourished and of good color. He was perfectly clear men- 
tally. There was no paralysis of any of the muscles controlled 
by the cranial nerves. The tongue was slightly coated; 
the throat was normal. The heart, lungs and abdomen 
were normal. The liver and spleen were not palpable. 
He used his arms freely. He held up his head well. He 
could sit alone, but rather feebly, the feebleness being due 
to the insufficiency of his legs. There was no deformity of 
the spine, which was normally flexible. The only motion 
which he could make with his legs was to flex the left toes a 
little. When the thighs were flexed on the body he could 
hold the left one there for an instant; the right dropped 
outward at once. The bones and joints were normal. 
Passive motions were not limited or painful. The abdominal 
and cremasteric reflexes were normal. The knee-jerks were 
absent on both sides. Kernig's and Babinski's signs were 
absent. Sensation to touch and pain was normal. There 
was no enlargement of the peripheral lymph nodes. The 
rectal temperature was 99 F. 

Diagnosis. The history and physical examination exclude 



DISEASES OF THE NERVOUS SYSTEM. 287 

at once, of course, injuries and diseases of the bones and 
joints. Rheumatism is not accompanied by flaccid paralysis. 
The paralysis must be due, therefore, to some disease of the 
nervous system. The absence of all symptoms of meningeal 
irritation, the clear mind, the paraplegic distribution of the 
paralysis and the absence of the knee-jerks exclude disease 
of the brain. The sudden onset and the absence of disturb- 
ances of sensation rule out disease of the peripheral nerves. 
The lesion must, therefore, be located in the spinal cord. 
The combination of loss of power and reflexes without dis- 
turbance of sensation occurs only in lesions of the anterior 
horns. Such lesions develop acutely in childhood only in the 
disease known as Infantile Paralysis. This is, therefore, 
the diagnosis. 

Prognosis. The chance of the extension of the process 
upward and of involvement of the respiratory muscles is so 
slight that a positively favorable prognosis as to life is allow- 
able. There will, in fact, in all probability be no further 
extension of the paralysis. The paralysis is certain to im- 
prove a great deal. It is impossible to state now how great 
the improvement will be. He may recover entirely, but will 
in all probability be left with considerable disability in the 
right leg and a little in the left. There will be little improve- 
ment after the first six months. 

Treatment. Nothing whatever can be done to modify the 
pathological process in the nervous system. There are no 
drugs which can possibly do any good, since the harm is 
already done. It is unreasonable to expect external applica- 
tions to have any effect on the spinal cord, which is located 
inside the vertebral column and has an entirely different blood 
supply from the superficial tissues. The only thing that they 
can do is to disturb the patient. While nothing can be done 
to shorten the course of the disease or to limit its progress, 
there is no doubt that the use or the attempted use of the 
extremities involved tends, during the acute stage, to delay 
the process of repair in the nervous system and possibly, 
very early, to favor the extension of the process. He should, 
therefore, be kept as quiet as possible for six weeks, when the 
acute stage is presumably over. If he has much pain, he 



288 CASE HISTORIES IN PEDIATRICS. 

should be kept quiet for three weeks after the cessation of 
the pain. Massage and electricity have the same action as 
the use of the extremities and should not, therefore, be begun 
for six weeks. It is very important during this period, how- 
ever, to prevent the development of contractures, which make 
the subsequent treatment much more difficult. The weight 
of the bedclothes must be kept off of his legs by a cradle. 
A light wire splint will prevent extension of the feet and 
flexion of the knees. Strychnia is a stimulant to the motor 
nerves and is, therefore, contra-indicated during the acute 
stage. Hexamethylenamine cannot be expected to do any 
good now, since the harm is already done. It is possible, how- 
ever, that it may destroy or inhibit the growth of the micro- 
organisms which cause the disease and prevent them from 
escaping from the body and causing the disease in others. 
It will be well, therefore, to give him three grains of hexa- 
methylenamine three times daily. It goes without saying, 
of course, that he must have good food and plenty of it, a 
liberal amount of fresh air and sunlight and good care in 
general. 

After the expiration of the acute stage he can begin to try 
to use his legs, must have vigorous and active treatment by 
electricity and massage and will be helped by strychnia. 
Treatment is most effectual during the first six months. 
Little improvement can be expected after this time, except 
from muscle training. It is extremely important, therefore, 
to give him every attention during this time and not to put 
off treatment until some future period. 



DISEASES OF THE NERVOUS SYSTEM. 289 

CASE 94. Joseph R., four years old, was the child of 
healthy parents. Five other children were well and there 
had been no deaths or miscarriages. There had been no known 
exposure to tuberculosis. 

He was born at full term after a normal labor, was normal 
at birth and weighed ten pounds. He w T as nursed for ten 
months and did very well. He had otitis media, followed by 
mastoid inflammation and operation, when he was one and 
one-half years old, but made a perfect recovery. He had 
measles when three and one-half years old and mumps a 
few months later, but had otherwise been well and strong. 
He was said to have had pneumonia, lasting eight or nine 
days, in the early part of December, but was not very sick, 
and had no marked cerebral symptoms. Soon after getting 
up from the " pneumonia " he began to stagger a little, " as 
if drunk." The staggering increased rather rapidly in severity 
for a time and then remained unchanged. He also began to 
complain of occipital headache at about the same time. The 
headache was, however, never very severe, was not continu- 
ous and did not prevent him from sleeping. He began to 
vomit about Christmas and had continued to do so. The 
vomiting had no apparent relation to food. There were no 
other signs of indigestion, his appetite was good and his 
bow^els moved regularly. He sometimes vomited with great 
force. He was bright and happy when his head did not ache, 
and played as much as his unsteady gait would permit. 
He had no trouble with sight or hearing and his memory was 
good. He was seen January 28. 

Physical Examination. He was fairly developed and nour- 
ished and of good color. His skin was rather dry. He was 
perfectly clear mentally. There was no tenderness on per- 
cussion of the skull. Macewen's sign was absent. There was 
no rigidity of the neck. He both saw and heard. The ear- 
drums were normal. The pupils were equal and reacted to 
light. The right eye showed an optic neuritis of the choked- 
disk type with a fair amount of swelling; the left eye showed 
similar but less marked changes. There was no spasm or 
paralysis of any of the muscles controlled by the cranial 
nerves. He held his head up straight and sat up straight. 



29O CASE HISTORIES IN PEDIATRICS. 

His tongue was clean and the mouth and throat normal. The 
heart, lungs and abdomen were normal. The liver and spleen 
were not palpable. He used his hands normally. He walked 
a little unsteadily and, on turning, staggered and almost fell. 
There was no tendency to fall to one side more than to the 
other. There was no spasm of the legs, and when lying down 
he could make all motions without difficulty. The knee-jerks 
were equal and normal. Kernig's and Babinski's signs were 
absent. The cremasteric and abdominal reflexes were normal. 
Sensation to touch and pain was normal by rough tests. The 
genitals were normal. There was no eruption and there were 
no scars of old eruptions. There was no enlargement of the 
peripheral lymph nodes. The mouth temperature was 
98. 6° F., the pulse 96, the respiration 24. 

The urine showed nothing abnormal. 

The white corpuscles numbered 8,000. 

A tuberculin skin test was negative. 

Diagnosis. The persistent vomiting without other symp- 
toms of indigestion, the projectile character of the vomiting, 
the occipital headache without disturbance of digestion, 
disease of the kidney or eyestrain, and the staggering gait 
without disease of the ears form a combination of symptoms 
that can be explained only by some trouble in the brain. 
The optic neuritis proves that there is a cerebral lesion. The 
condition is, of course, a chronic one. The first possibility 
which suggests itself is an abscess of the brain resulting from 
the otitis media two and one-half years before. Cerebral 
abscess is very rare at this age and a latent period of two and 
one-half years without any symptoms is most unusual. These 
facts, together with the normal condition of the ears and the 
absence of fever and leucocytosis, make an abscess extremely 
improbable. Another possibility is that the illness which was 
called pneumonia was, in spite of the lack of nervous symp- 
toms, an encephalitis and that the present symptoms are 
the result of it. It would be hardly possible, however, for an 
encephalitis to be mistaken for a pneumonia, although a 
pneumonia might easily be mistaken for an encephalitis. 
The lesions caused by an encephalitis would not be likely to 
cause an optic neuritis and would almost certainly produce 



DISEASES OF THE NERVOUS SYSTEM. 29 1 

some spasm, paralysis, change in the reflexes or mental dis- 
turbance. The most reasonable explanation for his symptoms 
is a rather rapidly growing cerebral tumor. The optic 
neuritis, projectile vomiting and staggering all point to it. 
The absence of Mace wen's sign does not count much against 
the presence of a tumor, because it is often hard to elicit and 
is often absent when the tumor is deep seated. The location 
of the pain in the occiput and the reeling gait make it probable 
that the Tumor is in the Cerebellum. The absence of spasm, 
paralysis and changes in the reflexes is negative evidence in 
favor of this location. Nearly forty per cent of cerebral 
tumors in childhood are, moreover, in the cerebellum. 

It is impossible to more than guess at the nature of the 
tumor. The negative tuberculin test practically rules out a 
solitary tubercle, although about fifty per cent of the cerebral 
tumors in childhood are tubercular. Gumma is extremely 
rare at this age, the family history is good, there is nothing 
in his past history to suggest syphilis, and the physical exami- 
nation shows no sign of syphilis in the past or at present. A 
gumma can, therefore, be excluded. The chances lie between 
a glioma and a sarcoma, the former being somewhat the more 
probable as gliomata are more common than sarcomata at 
this age. 

Prognosis. The prognosis is hopeless. He will probably 
not live more than three or four months, perhaps not as long. 

Treatment. The treatment can be only symptomatic and 
for comfort. He must not be allowed to suffer pain when 
morphia will relieve him. It will be well, perhaps, to give him 
iodide of potash up to the physiological limit on the possi- 
bility that the tumor may be a gumma. It will probably do 
no good, but can do no harm. The chances of the successful 
removal of the tumor by an operation are practically nil. 
It will be only fair, however, to state the facts to the parents 
and allow them to decide as to whether or not they wish an 
operation. A lumbar puncture should not be done because 
it is very likely to cause sudden death when there is a cerebral 
tumor, especially if it is located in the cerebellum. 



292 CASE HISTORIES IN PEDIATRICS. 

CASE 95. Ambrose M., nine years old, had a sore throat 
the last week in March. He was not sick enough to be in bed 
and no physician was called. He returned to school after a 
week. His voice became somewhat unnatural about April 
25, and several days later liquids began to come through his 
nose when he drank. He found, May 1, that he could not 
see the blackboard very well, and a few days later began to 
have some difficulty in walking steadily. These symptoms 
were all present when he was seen, May 6. 

Physical Examination. He was well developed and nour- 
ished, but rather pale. His tongue was clean and was pro- 
truded in the median line. The gums were healthy. His 
throat was normal, except that the soft palate moved but 
little when he spoke. His voice was somewhat hoarse. 
There was moderate internal strabismus on the right. The 
pupils were equal and reacted to both light and accommoda- 
tion. The heart, lungs and abdomen were normal. The 
liver and spleen were not palpable. He moved his arms freely 
and his grip was strong. He moved his legs freely but with 
little muscular power. He walked a little unsteadily. His 
legs felt flabby and were rather cool. The knee-jerks were 
absent on both sides. The abdominal and cremasteric re- 
flexes were somewhat diminished. Kernig's and Babinski's 
signs were absent. Sensation to touch was somewhat blunted, 
but that to pain and temperature was normal. There was 
no tenderness anywhere. There was no enlargement of the 
peripheral lymph nodes. 

The urine was normal in color, acid in reaction and of a 
specific gravity of 1,018. It contained neither albumin nor 
sugar. 

Diagnosis. The paresis of the legs in combination with the 
loss of the knee-jerks suggests to a certain extent infantile 
paralysis. A slow onset and a paraplegic distribution of the 
paralysis are, however, uncommon in infantile paralysis. 
The disturbance of sensation shows that the lesion is in the 
peripheral nerves, not in the anterior horns. The paresis of 
the soft palate and of the right external rectus is, moreover, 
not consistent with infantile paralysis, because, even with our 
present conception of the pathology of this disease, it would 



DISEASES OF THE NERVOUS SYSTEM. 293 

be hard to conceive of a poliomyelo-encephalitis resulting in 
paresis of the legs, one muscle of one eye and the soft palate 
and nothing else. The only possible explanation of this com- 
bination in a child of nine is a peripheral paralysis. 

This combination is almost pathognomonic of diphtheritic 
paralysis. The absence of pain and tenderness is also very 
characteristic. The history of a sore throat a few weeks 
before the onset of the paralysis makes the diagnosis of 
Diphtheritic Paralysis positive. The only other form 
of peripheral paralysis at all likely to occur in childhood, 
that due to lead poisoning, can be excluded, not only be- 
cause of the typical picture of diphtheritic paralysis which 
this boy presents, but also on the distribution of the paralysis 
and the absence of pain and tenderness and of a lead line 
on the gums. 

Prognosis. The prognosis is good. He will probably 
recover from the paresis of the eye and throat in six or eight 
weeks. The legs will probably not be well for from four to 
six months. The reflexes will not return until some time 
later. 

Treatment. He must not use his eyes for near work. 
It will be easier for him to take solid or semi-solid than 
liquid food. He must be kept reasonably quiet. Exercise, 
except in moderation, retards rather than hastens recovery. 
Care must be taken to prevent, by the use of passive motions 
or apparatus, the development of contractures. Massage 
and electricity must be begun at once. Faradism is prefer- 
able, if the muscles react to it; if they do not, galvanism 
must be used. It must be remembered in this connection 
that the object of both massage and electricity is merely to 
keep the muscles in good condition until the nerves resume 
their function, and that they have no direct curative action 
on the nerves. He should be given strychnia in doses of 
from one-sixtieth to one- thirtieth of a grain, three times 
daily, after eating. 



294 CASE HISTORIES IN PEDIATRICS. 

CASE 96. Elizabeth C, three years old, was the only 
child of extremely neurotic but healthy parents. There had 
been no miscarriages. She had always been well. 

Her mother left her with an attendant one afternoon. 
She was pulled up from the floor by the arms a number of 
times and had also swung on a gate with her arms extended. 
She had had no fall. She complained a little of pain in her 
left arm before she went to bed, but nothing was thought of 
it. No one could tell whether she used her arm or not during 
the late afternoon before she went to bed. She slept well 
all night, seemed perfectly well in the morning and ate a 
good breakfast, but did not use her lelt arm at all. She 
apparently had no pain in it. She was seen at 2 p.m. 

Physical Examination. She was well developed and nour- 
ished and of good color. She was very bright and much 
interested in her surroundings. There was no rigidity of 
the neck and no paralysis of any of the muscles controlled 
by the cranial nerves. She had twenty teeth. Her tongue 
was clean; her gums, mouth and throat were normal. There 
was a slight rosary. The heart and lungs were normal. 
The abdomen was rather large and lax, but otherwise normal. 
The liver and spleen were not palpable. Her left arm hung 
limply by her side with the palm turned backward and the 
fingers partially flexed. She would not reach out for or take 
hold of anything. There was no tenderness about the joints 
or bones or along the nerve trunks. There were no evidences 
of fracture or dislocation. There was no swelling or redness. 
Passive motions were not limited or painful. There was 
apparently no disturbance of the sensations to touch or 
pain. The reflexes of the arms were normal. She used her 
right arm and legs freely. The knee-jerks were equal and 
normal. Kernig's and Babinski's signs were absent. She 
was slightly knock-kneed, but there was no enlargement of 
the epiphyses at the wrists and ankles. There was no enlarge- 
ment of the peripheral lymph nodes. There were no mucous 
patches and no eruption or signs of old eruptions. The 
rectal temperature was 98. 6° F. 

Diagnosis. Scurvy, while a possibility, is very improbable 
in a child of three on a general diet. It can be excluded on 



DISEASES OF THE NERVOUS SYSTEM. 295 

the localization of the symptoms in one extremity, the 
absence of pain on pas si notion and the absence of swelling- 
and tenderness. Syphilitic periosteitis can be ruled out on 
the good family and past history, the absence of signs of 
syphilis in the past or present, the absence of local tenderness 
and swelling, and the localization in one extremity. Acute 
periosteitis or osteomyelitis can be excluded on the good 
general condition and the absence of fever, pain and tender- 
ness. The history of fleeting pain is like that of rheumatism 
at this age. Children do not stop using their extremities 
when they have rheumatism, however, and the pain is usually 
more general. The onset and development of the paralysis, 
although unusual, are not inconsistent with infantile paraly- 
sis, but the absence of fever and the retention of the reflexes 
practically exclude it. The position of the arm suggests 
that there may have been some pressure on the brachial 
plexus. It is hard to see how this could have happened in her 
case, and the absence of disturbances of sensation makes it 
very improbable. There is no dislocation or evidence of 
injury to the arm at present. It is very possible, however, 
that there may have been a partial dislocation of the shoulder 
as the result of the pulling up by the arms or of the swinging, 
with immediate spontaneous reduction. The subconscious 
memory of the pain caused by motion of the arm at that 
time may account for the failure to use it now. This seems, 
at any rate, the most plausible explanation. In an older 
child or adult it would be called an Hysterical Paralysis. 

Prognosis. The prognosis is perfectly good. If she can 
be sufficiently interested in some game or toy to forget 
herself entirely, she will use the arm at once. 

Treatment. The treatment consists in getting her mind 
entirely off of herself so that she will unconsciously use the 
arm again. 



SECTION XII. 

UNCLASSIFIED DISEASES. 

CASE 97. Sadie H. was the first child of healthy parents. 
There had been no miscarriages. Her parents were Russians 
and not related. There was no history of idiocy or nervous 
diseases in either family. 

She was born at full term after a normal labor, and seemed 
normal at birth. She was nursed for ten months, after which 
she was given a general diet. Her appetite and digestion 
had always been good. Constipation began when she was 
two months old and had persisted. A dry and scaly condi- 
tion of the face, scalp and extremities developed when she 
was three months old and had resisted all forms of treatment. 
She had rather more hair than most children at birth, but 
this soon dropped out and no more appeared until she was 
nearly two years old. Her mother noticed when she was six 
months old that her tongue seemed too large for her mouth 
and that she drooled more than most babies. When she was 
eight months old her mother noticed that she was not as 
bright as other children of her age. Her mental development 
had, as time went on, dropped progressively farther behind 
that of other children of her own age. She was seen when 
three and one-fourth years old, and could then say only 
a few words. Her parents thought, however, that she 
understood much of what was said to her. She had not 
learned to control her sphincters. She cut her first tooth 
when she was two years old and began to sit up a little 
when she was two and one-fourth years old. She had not 
learned to creep or stand. Her large tongue made swallowing 
difficult and she drooled constantly. 

Physical Examination. She took considerable interest in 
her surroundings, but made no attempt to play with the 
toys offered to her, although she held them in her hands for 
a time. She knew her parents and said :< Papa " and 

297 



298 CASE HISTORIES IN PEDIATRICS. 

" Mamma " and a few other simple words. She was small 
but fairly nourished. Her skin had a peculiar yellowish 
pallor. She had considerable rather coarse hair. The face 
and the top of the head were covered with a dry, scaly erup- 
tion. The anterior fontanelle was closed. The head was of 
good shape, except that it was somewhat flattened on top. 
The bridge of the nose was flattened and the nostrils wide. 
The lower lids were rather full. She kept her mouth open and 
drooled constantly. The thickened and broadened tongue 
protruded just beyond the lips. She had six incisor teeth 
which, although only just through the gums, were much 
blackened. The throat was normal. Her voice was hoarse 
and deep. The rings of the trachea were distinctly pal- 
pable. The neck was not especially short, and there were no 
supraclavicular pads. She held up her head well but sat up 
rather feebly, with a marked general kyphosis. This was 
replaced by a slight lordosis in the lumbar region when she 
was held upright. There was a moderate rosary and a little 
flaring of the lower ribs. The heart and lungs were normal. 
The level of the abdomen was much above that of the thorax, 
but nothing else abnormal was detected in it. The lower 
border of the liver was palpable just below the costal border 
in the nipple line. The spleen was not palpable. The lower 
legs and feet appeared puffy but did not pit on pressure. 
The soles of the feet were flat, like those of an infant. The 
forearms and hands were also puffy, especially in the palms. 
The hands and feet were cold and the skin of the legs, feet, 
arms and hands dry, and in places scaly. There w T as no 
enlargement of the epiphyses, but the long bones of the 
extremities seemed larger in circumference than normal. 
The distance from the anterior superior spine to the sole of 
the foot was forty-four per cent of the body length, while 
it should be about fifty per cent. There was no spasm or 
paralysis. The knee-jerks were equal and diminished. 
Kernig's sign was absent. The external genitals were normal. 
There was a slight general enlargement of the peripheral 
lymph nodes. The rectal temperature was 98 F. She 
weighed twenty-two and one-half pounds (average is thirty- 
four and one-half pounds). 



UNCLASSIFIED DISEASES. 299 

Diagnosis. The history and physical examination of this 
child are so characteristic of Sporadic Cretinism that there 
is no opportunity for a differential diagnosis. The com- 
bination of retarded mental and physical development, 
yellowish pallor, coarse hair, dry and scaly skin, thickening 
of the skin of the extremities, broad nose, large tongue, 
hoarse and deep voice, apparent absence of the thyroid 
gland, short legs, thickening of the long bones of the extremi- 
ties and subnormal temperature is pathognomonic of the 
disease. The flattening of the head, the rosary and the 
flaring of the lower ribs are undoubtedly signs of a compli- 
cating rickets. The delayed dentition, the kyphosis and the 
enlargement of the abdomen may be due to either, but more 
probably to the cretinism. 

Prognosis. She will undoubtedly improve very materially, 
both mentally and physically, but too much must not be 
expected from the thyroid treatment when it is not begun 
until the patient is over three years old. The physical 
improvement will probably be much greater and more rapid 
than the mental. She will almost certainly, however, not 
attain normal stature, although her proportions will probably 
be approximately normal and she will be reasonably active. 
She will probably never develop sufficiently mentally to be 
a free agent or to support herself, although she will probably 
be able to do manual labor. 

Treatment. The treatment is with some preparation of 
the thyroid gland. The best preparation is the dessicated 
extract. The initial dose for this child is one half a grain, 
three times a day. It must be increased, one quarter of a 
grain at a time, until toxic symptoms appear. These are 
nervousness, fever and diarrhea. The dose must then be 
put back to the largest one which did not cause toxic symp- 
toms and kept there for many months. Later, it may be 
safe to give smaller doses. It is needless to say that she 
must continue to take thyroid extract as long as she lives. 
Her father's financial condition is poor. It will be wise, 
therefore, to place her in some institution for the care of 
the feeble-minded. 



300 CASE HISTORIES IN PEDIATRICS. 

CASE 98. Lincoln F., fifteen months old, was the second 
child of healthy parents. There had been no deaths* or 
miscarriages. He was born at full term after a normal 
labor, was normal at birth and weighed ten pounds. He was 
nursed for seven months and then given modified cow's 
milk prepared at home, on which he did very well. Oatmeal 
water was added to his milk when he was eleven months old, 
but had to be stopped because it caused hives. He was then 
put on whole milk and mutton broth. Barley water had 
recently been added to the milk. He had lost his appetite 
during the last month, but had had no nausea or vomiting. 
He had been having from four to five small, green, foul 
movements, containing small curds and mucus, daily. He 
had been fussy and had had some colic. He had lost nearly 
two pounds in weight. 

Five days before he was seen all milk had been stopped 
and he had been put on beef juice, broth, white of egg and 
cereal jellies. He took his new food well and seemed better 
for three days, but had been very fussy the last two days, 
and had had five movements daily. These were loose, very 
dark in color and had a very foul odor. Swelling of the 
face appeared the day before, and that morning his hands and 
feet were also swollen. He was seen at 2 p.m. 

Physical Examination. He was well developed and nour- 
ished, but rather flabby. His color was fair. The anterior 
fontanelle was nearly closed. His face was somewhat puffy, 
especially about the eyes. It was not reddened, but evidently 
itched. He had three teeth. The gums, mouth and throat 
were normal, the tongue moderately coated. There was no 
venous hum in the neck. There was a slight rosary. The 
heart, lungs and abdomen were normal. The liver was 
palpable 2 cm. below the costal border in the nipple line. 
The spleen was not palpable. The extremities were normal, 
except that the hands and feet were somewhat swollen. 
The swelling was not hot or red and did not pit on pressure. 
There was no spasm or paralysis. The knee-jerks were not 
obtained. Kernig's sign was absent. There was a slight 
general enlargement of the peripheral lymph nodes. The 
rectal temperature was normal. 



UNCLASSIFIED DISEASES. 301 

The urine was high in color, turbid, very acid in reaction, 
of a specific gravity of 1,024, an d contained no albumin or 
sugar. The sediment consisted of crystals of urate of 
ammonium. 

Blood. 

Hemoglobin, 65% 

Red corpuscles, 5,240,000 

White corpuscles, 12,000 

Diagnosis. He undoubtedly has a chronic intestinal 
indigestion and a slight amount of rickets. The condition 
which requires explanation is the swelling of the face, hands 
and feet. The analysis of the urine shows that it cannot 
be due to disease of the kidney, the heart is normal and, 
while the blood shows a very slight degree of anemia, it is 
not sufficient to cause edema, and there is no venous hum in 
the neck. The swelling does not pit on pressure, moreover, 
and itches, showing that it is not an ordinary edema. It 
must, therefore, belong in the class of the Angioneurotic 
Edemas. These are in all probability due to some dis- 
turbance of the vasomotor control of the blood vessels. 
In this instance the edema is almost certainly connected in 
some way with the intestinal disturbance. It may be due 
either to irritation of the terminal sympathetic fibers in the 
walls of the intestines or to the absorption of toxic or chemical 
irritants from the intestines which act directly on the vas- 
cular terminal filaments of the sympathetic. It is, of course, 
impossible to say which. Its appearance at this time is 
probably connected with the change of food five days before, 
since no other element has been introduced. It cannot be 
due to the broth or jellies, because he has had broth and 
barley before without the appearance of edema. It must be 
due, therefore, to either the beef juice or the white of egg. 
The excessively foul odor of the stools suggests decomposi- 
tion of the beef juice and the production of toxic substances, 
while white of egg is known to be the food which most often 
causes angioneurotic edema. 

Prognosis. There is no danger connected with the an- 
gioneurotic edema. It is merely a side issue and does not 
alter the prognosis of the original intestinal indigestion. 



302 CASE HISTORIES IN PEDIATRICS. 

Treatment. The first thing to do is to stop both the beef 
juice and white of egg, either or both of which may be the 
cause of the swelling. The next thing to do is to give him 
two teaspoonfuls of castor oil to empty the intestines of the 
toxic products of the decomposition of the beef juice and 
egg, which they probably contain. It will be well to stop 
his food for twenty- four hours, giving him in its place at 
least one quart of water. Alkalies seem to hasten the disap- 
pearance of angioneurotic edema. He should, therefore, 
be given about a dram of the citrate or acetate of potash or 
of bicarbonate of soda, in water, during the twenty-four 
hours. Equal parts of skimmed milk and barley water will 
be a suitable mixture with which to begin, after the day of 
water diet. 



UN'CLASSIFIED DISEASES. 303 

CASE 99. George R., two and one-half years old, was 
the child of healthy parents. There were four other children 
living and well, none had died and there had been no mis- 
carriages. He had always been nervous but had had no 
illnesses. He had had nothing to eat the night before the 
onset of the present illness that had not been eaten by the 
rest of the family, but had been playing out in the snow that 
day and had got rather wet. 

He had a number of attacks of rather severe abdominal 
pain, lasting from fifteen minutes to an hour, during the night 
of January n. He had no other symptoms and appeared all 
right the next day. Both ankles became painful and swollen 
January 13, and purpuric spots appeared on the ankles and 
lower legs the next day. That day he had a very severe 
attack of abdominal pain, followed by vomiting and diarrhea 
which lasted for about twelve hours. Xeither the vomitus 
nor the stools contained blood. He was seen January 15 
by his physician, who found nothing abnormal on physical 
examination, except that both ankles were a little swollen 
and tender and had purpuric spots about them. The tempera- 
ture was then 99 F. and the pulse 140. He continued to have 
attacks of severe abdominal pain, lasting from one hour to 
two hours, but had no other symptoms of indigestion and the 
bowels moved normally. Both abdominal and rectal exami- 
nations were normal on January 18. The urine showed nothing 
abnormal. The temperature had varied between normal and 
99 F., the pulse between 120 and 150. 

He did well from that time to January 24, when his scrotum 
and penis suddenly became much swollen, the scrotum being 
nearly three times its usual size and very painful. The 
swelling was pinkish in color and did not pit on pressure. It 
lasted but a few hours. Purpuric spots appeared on the but- 
tocks at the same time. A similar swelling, the size of the 
palm of the hand, appeared over the sacrum the next day and 
disappeared again in a few hours. More purpuric spots also 
appeared on the buttocks. The attacks of abdominal pain re- 
curred on the 27th. Between them he apparently felt perfectly 
well. He had no fever. He had been kept on a light diet 
from the beginning, but this included eggs and broth. He 



304 CASE HISTORIES IN PEDIATRICS. 

was given citrate of potash at first and later three grains of 
the lactate of calcium daily. His bowels had been kept well 
open. He was seen in consultation January 28. 

Physical Examination. He was well developed and nour- 
ished and of good color. His tongue was slightly coated, his 
teeth in good condition. His gums and throat were normal. 
His heart and lungs were normal. The abdomen was a 
little sunken and showed nothing abnormal. There were no 
masses, no tenderness and no muscular spasm. The liver 
and spleen were not palpable. The penis and scrotum were 
normal. The extremities were normal. There was no spasm 
or paralysis. The knee-jerks were equal and normal. There 
was no Kernig's sign. There was no enlargement of the 
peripheral lymph nodes. There were a few fading purpuric 
spots about the ankles and buttocks. A rectal examination 
showed nothing abnormal. 

The urine was normal in color, clear, acid in reaction and 
of a specific gravity of 1,016. It contained neither albumin 
nor sugar. The centrifugalized sediment showed an excess of 
urates and an occasional small round cell, but no casts. 

Diagnosis. The attacks of abdominal pain with the at- 
tendant vomiting and diarrhea, the swelling and the purpuric 
eruption about the ankles, and the swelling and purpuric 
eruption about the genitals and buttocks are undoubtedly 
merely different manifestations of some abnormal systemic 
condition. The swellings which appeared in the genitals and 
over the sacrum have all the characteristics of angioneurotic 
edema. The eruption on the buttocks deserves the name of 
purpura simplex. The swelling and eruption about the ankles 
is typical of purpura rheumatica. The attacks of abdominal 
pain would be very hard to explain if they occurred alone, 
but associated, as they are, w^ith other manifestations of 
purpura, they are quite characteristic of the condition known 
as abdominal purpura or Henoch's disease. Giving these 
various symptoms names does not, however, bring us much 
nearer the diagnosis of the underlying condition. It does 
emphasize the fact, however, that it is not justifiable to 
describe the different forms of Purpura as if they were dif- 
ferent diseases, and shows that they are merely different 



UNCLASSIFIED DISEASES. 305 

manifestations of the same condition. The association of 
the condition known as angioneurotic edema, which is pre- 
sumably due to a disturbance of the nervous control of the 
walls of the blood vessels, with the purpuric condition makes 
it probable that the purpura is due to some toxic action on 
the vessel walls rather than to a bacterial infection. This 
assumption is supported by the absence of fever. The 
presence of the angioneurotic edema in association with the 
purpura also makes it probable that the purpuric condition 
is not due to any disturbance of the coagulability of the blood. 
There is nothing in the history or physical examination to 
suggest the origin of the toxic substance. The normal con- 
dition of the gums and the good health of the other members 
of the family rule out lead poisoning. The good health of the 
rest of the family and the absence of symptoms of indigestion 
make intestinal toxemia very improbable. The etiology 
must, therefore, remain unsettled. It is possible that the 
eggs and broth may have had something to do with the con- 
tinuance of the condition, as they not infrequently cause 
angioneurotic edema. The attacks of abdominal pain may 
be due to an angioneurotic edema of the intestinal wall or to 
a hemorrhage into the wall. The short duration of the attacks 
and their frequent repetition, as well as the absence of blood 
in the stools, makes an edematous condition much more 
probable than a hemorrhagic. 

Prognosis. There is no danger as to life unless, as some- 
times happens, the local swelling in the intestinal wall 
causes an intussusception. The prognosis as to duration is, 
however, very indefinite as the condition not infrequently 
persists, with longer or shorter intermissions, for many weeks 
or even months. 

Treatment. The etiology being so obscure, the treatment 
can only be along general lines. He must be protected from 
chilling and overexertion. His diet should be limited to milk 
and starches, as they are less likely to form toxic substances 
in the intestines than are the fats and proteids. He must be 
given plenty of water and his bowels kept well open, preferably 
with salines. Although the calcium salts have no special 
influence on the coagulability of the blood, they have seemed 



306 CASE HISTORIES IN PEDIATRICS. 

clinically to be of some use in the treatment of angioneurotic 
edema and similar conditions. It will be well, therefore, to 
continue the lactate of calcium, but in larger doses, giving ten 
grains daily. Animal sera hardly seem indicated at present 
in this instance, because, if our reasoning is correct, the 
difficulty is not impaired coagulability of the blood. If the 
purpuric eruptions continue to recur, or if there are hemor- 
rhages elsewhere, it will be wise, nevertheless, to give them a 
trial. (See Case 5.) 

Heat externally and paregoric, in doses of fifteen or more 
drops, may be employed for the attacks of pain. 



UNCLASSIFIED DISEASES. T>°7 

CASE ioo. Charles W., eleven years old, was the child of 
healthy parents. One brother was living and well. There 
had been no deaths or miscarriages. His maternal grandfather 
had had diabetes, but had died of tuberculosis. 

He was born at full term, was normal at birth and weighed 
six pounds. He had whooping-cough when one year old, 
mumps and chicken-pox when small, and measles at four years, 
but had otherwise been well. He had always eaten much 
candy and had craved sweet foods. He had passed much 
more urine during the last month than formerly, and had 
drunk large quantities of water. He had to get up several 
times at night to urinate and to allay his thirst. His appetite 
was large. He had had no itching of the skin and no eruption. 
He was admitted to the Children's Hospital, August 3. 

Physical Examination. He was small and sparely 
nourished. He was moderately pale, but did not look or act 
sick. His skin was not dry or irritated, and there was no 
eruption. His tongue was slightly coated, the mouth and 
throat normal. The heart, lungs and abdomen were normal. 
The liver and spleen were not palpable. The extremities were 
normal. There was no spasm or paralysis. The knee-jerks 
were equal and lively. There was no disturbance of sensation. 
There was no enlargement of the peripheral lymph nodes. 
He weighed fifty- two pounds. 

He was allowed to eat as much as he wanted of the regular 
hospital diet, but was not allowed to put sugar on his food. 
He passed 560 ccm. of urine (the normal average is 1,200 
ccm.) August 4, of a specific gravity of 1,041, which con- 
tained 5.9% or 33.6 grams of sugar. It contained no albumin 
or acetone, and the sediment showed nothing abnormal. 

An accurate account of what he ate was then kept. He 
took 85 grams of carbohydrates August 6 and passed 855 ccm. 
of urine of a specific gravity of 1,018, which contained 1.8% 
or 15.3 grams of sugar, but no acetone. 

Diagnosis. There can be no doubt, of course, as to the 
diagnosis of Diabetes Mellitus. A simple glycosuria can 
be excluded on the persistence of the symptoms and the 
presence of sugar in the urine when there is only a moderate 
amount of carbohydrates in the food. 



308 CASE HISTORIES IN PEDIATRICS. 

Prognosis. There is practically no chance that he will 
recover, although, judging from the fact that he was able to 
make use of 70 grams of carbohydrates in twenty-four hours, 
the disease is not of a very severe type. His expectation 
of life is probably to be reckoned in months rather than in 
years, but he may, with careful treatment, live for a number 
of years. He is, however, very likely to suddenly develop 
acid intoxication at any time and die after a few days. 

Treatment. Drugs are of no use in the treatment of dia- 
betes. The treatment consists in regulation of the diet. The 
principles are simple. The diet must contain calories enough 
to supply the caloric needs. The carbohydrates must be 
cut down until the urine is free from sugar, but no lower 
than is necessary to accomplish this, because of the danger 
of the development of acid intoxication. If the acetone 
bodies appear in the urine when the carbohydrates are cut 
down, they must be increased again until the acetone bodies 
disappear. If the amount of the acetone bodies is small, it 
is safe for a time, however, not to increase the carbohydrates, 
but to neutralize the acetone bodies by giving bicarbonate 
of soda. The water should not be limited. 

A boy of his size needs approximately 1,300 calories daily. 
It is a simple matter to lay out a diet for him which will 
contain the proper number of calories and to regulate the 
amount of carbohydrates which it contains by the use of the 
table of food values given in Case 73. 

His diet August 13 was as follows: 

Calories. Carbohydrates. 

Cereal, I J oz.= 37.5 8.2 grams. 

Rice, i§ oz. = 67.5 15 grams. 

Bread, 1 oz. = 75 15 grams. 

Meat, 6J oz. = 390 

Eggs, 4= 288 

Butter, 3 oz. = 675 

Tomato, 9 oz. = . . . 



1,533 38.2 grams, 

He passed 530 ccm. of urine of a specific gravity of 1,010, 
which contained neither sugar nor acetone. 



UNCLASSIFIED DISEASES. 



309 



The urine contained acetone the next day, however, al- 
though the amount of carbohydrates in the food was the same. 
The amount of carbohydrates was, therefore, gradually in- 
creased, so that on August 17 he was taking 76 grams. He 
passed on that day 470 ccm. of urine of a specific gravity of 
1,026, which contained 2.3% or 10.8 grams of sugar, but no 
acetone. 

It was evident, therefore, that his tolerance for carbo- 
hydrates lay somewhere between 38 grams and 76 grams. 
A little more experimenting showed that he could take about 
55 grams of carbohydrates without the appearance of sugar 
in the urine, and that this amount prevented the formation 
of the acetone bodies. The diet and the examination of the 
urine on August 29 were as follows: 



Cereal, i| oz. = 
Rice, 1 J oz. = 
Bread, 2 oz. = 
Meat, 5^ oz. = 
Eggs, 4 = 
Butter, ij oz. = 
Broth, 6 oz. = 
Cucumber, 4 oz. = 



Calories. 


Carbohydrates. 


37-5 


8.2 grams 


67.5 


15 grams 


150 


30 grams 


330 




288 




337.5 




1,210.5 


53.2 grams 



He passed 650 ccm. of urine of a specific gravity of 1,016, 
which contained neither sugar nor acetone. 

On this diet he held his weight and had no symptoms. 
This diet should, therefore, be continued. It is unnecessary 
to consider the use of any of the so-called " diabetic foods " 
when he can take as much carbohydrate as at present. 



INDEX. 



The heavy face numerals refer to the pages on which the disease named is the diagnosis of a 
case: the other figures to page on which the disease or condition is mentioned. 



Abscess, cerebral, 290. 

epigastric, 27. 

hepatic, 215. 

peritonsillar, 158. 

retropharyngeal, 149, 158. 
Acid intoxication, 44, 45. 
Adenitis, bronchial, 33, 174, 247. 

cervical, 195. 

peripheral, 102. 

retroperitoneal, 236. 
Adenoids, 149, 154, 155, 165, 257. 
Albumin water (see infant feeding). 
Alkalies (see infant feeding). 
Anemia, chlorotic type, 106, 238. 

infantum pseudoleukemica, 245. 

pernicious, 242, 244. 

secondary, 105, 163, 213, 238, 242, 
245, 251, 301. 

secondary with splenic tumor, 246, 
254. 

splenic, 254. 
Angioneurotic edema, 273, 301, 304, 

305- 
Appendicitis, 66, 87, 89, 90, 122, 177, 

220. 
Ascites, 118, 209, 215, 225. 

causes of, 118. 

examination of fluid in, 119. 

physical signs of, 118. 
Atelectasis of lung, 19. 
Bacteriuria, 220, 231. 
Baths, fan, 182. 

pack, 182. 

sponge, 181. 
Bile ducts, congenital obliteration of, 
12, 29. 

obstruction of, 215. 
Bronchitis, 158, 169, 171, 174. 
Bronchopneumonia, 158, 169, 174. 
Calculi, renal, 223. 

vesical, 113. 



Calories, use in infant feeding, 53, 76, 
78, 81, 84, 92, 98, 100, 103, 115, 
246. 
use in older children. 136, 226, 227, 

308- 

method of calculation in infant feed- 
ing, 98. 

table of caloric values, 227. 
Caput succedaneum, 20. 
Cephalhematoma, 20. 
Cerebellar tumor, 291. 
Cerebral hemorrhage, 268, 276, 279. 
Cerebral paralysis, 279. 
Cerebrospinal fluid, normal, 126, 127. 

in meningitis, 126, 127. 
Chlorosis, 238. 
Cholecystitis, 66. 
Cholera infantum, 36, 94. 
Chorea, 257, 258. 

Cirrhosis of liver, 209, 212, 215, 254. 
Constipation, 51, 58, 61, 63, 75, 76, 79, 

83, 96, 101, 177, 260. 
Convulsions, 165, 180, 181, 260, 262, 
263, 269, 273. 

reflex, 261, 262, 264. 
Cretinism, 268, 299. 
Croup, spasmodic, 167. 
Dentition, difficult, 153. 
Diabetes mellitus, 307. 
Diarrhea, classification of, 35, 36. 

cholera infantum, 36, 94. 

dysenteric type, 36, 92, 114. 

fermentative, 36, 72, 75, 144. 

infectious, 36, 55, 75, 92, 115. 

nervous, 35. 
Diphtheria, 109, 138, 140, 149, 165, 
167, 220, 247, 293. 

laryngeal, 140, 165, 167. 

paralysis, 293. 

rhinitis, 138, 149. 
Emphysema, 185, 189. 



3ii 



312 



INDEX. 



Empyema, 185, 188, 189, 190. 
Encephalitis, 282, 283, 290. 
Epilepsy, 261, 262, 264. 
Fat (see infant feeding). 
Feeding (see infant feeding). 
Fissure of anus, 61. 
Gallstones, 66. 
Glioma, 291. 
Habit spasms, 258. 

Heart disease, acute endocarditis 198, 
201, 202. 

congenital, 18, 192. 

dilatation, 174, 198, 204. 

functional, 196. 

mitral insufficiency, 196, 201, 204. 

mitral stenosis, 204. 

myocarditis, 175, 198, 201. 
Hematuria, 112, 223. 
Hemophilia, 23. 

Hemorrhage, cerebral, 268, 276, 279. 
Hemorrhagic disease of the new-born, 

23. 
Hernia, inguinal, 30. 
Hip disease, 109. 
Hodgkin's disease, 248, 254. 
Hydrocele, encysted of cord, 31. 
Hydrocephalus, 105, 276. 
Hydronephrosis, 236. 
Icterus,, congenital, 12. 
Icterus neonatorum, 13. 
Idiocy, 267. 

amaurotic, 267, 270. 

hydrocephalic, 267. 

microcephalic, 268. 

Mongolian, 268. 
Indigestion, 153, 155. 

acute duodenal, 12, 66, 86. 

chronic duodenal, 29, 69, 215. 

acute gastric, 41, 47, 48, 58, 66, 78, 
134, 180. 

chronic gastric, 39, 51, 83. 

acute intestinal, 78. 

chronic intestinal, 36, 75, 101, 164, 
166, 262, 301. 

intestinal, disturbance of equilibrium, 
35, 75, 78, 80, 83. 

intestinal, fermentative type, 36, 72, 

75- 
Infant feeding, breast, 52, 73, 75, 81, 
83-99. 103,115. 166, 172,213,274. 
cow's milk, idiosyncrasy to, 52. 



use of low fat, 53, 73, 75, 81, 99. 

use of sugar, 73, 75, 81, 83, 92, 95, 
no, 166. 

use of starch, 73, 84, 92, 95, 99, 100, 
no, 166. 

use of proteids, j8, 99, 103. 

use of whey, 49, 73. 

use of whey proteids, 53, 73, 76, 84. 

use of alkalies, 53, 73, 76,81,84, 107, 
246. 
. use of pancreatization, 53, 84, no. 

use of albumin water, 92. 

use of calories, 53, 76, 78, 81, 84, 92, 
98, 100, 103, 115, 246. 

calculation of calories, 98. 

results of excess of fat, 36, 53, 63, 72, 
75, 80, 99. 

results of excess of sugar, 52, 78. 

results of excess of starch, 52. 

results of excess of proteids, 36, 83. 

results of insufficient food, 99. 

results of insufficient proteids, 103. 

pasteurization, disadvantages of , 113. 

boiling, disadvantages of, no. 
Infantile atrophy, 99, 102, 115. 
Influenza, 47, 135, 136, 143, 181, 208. 
Intestinal obstruction, 44, 58. 
Intestinal toxemia, 89, 128, 262, 276. 
Intussusception, 55, 58, 92, 305. 
Irrigation of bowels, method, 93. 
Kidney, passive congestion of, 209. 

sarcoma of, 112, 223, 236. 

tuberculosis of, 112, 223. 
Larygismus stridulus, 33, 165, 263, 264, 

273- 
Laryngitis, catarrhal, 140, 165, 167. 

diphtheritic, 140, 165, 167. 
Lavage, method, 48. 
Lead poisoning, 293. 
Leukemia, acute lymphatic, 218, 242, 

248, 251, 254. 
Liver, abscess of, 215. 

amyloid disease of, 212. 

cirrhosis of, 209, 212, 215, 254. 

fatty, 213. 

malignant disease of, 212, 215, 218. 

syphilis of, 215. 

tuberculosis of, 215. 
Malaria, 134, 142, 145, 162, 163, 230, 
241. 



INDEX. 



313 



Malnutrition, 36, 51, 80, 82, 99, 102, 
115- 

from insufficient food, 99. 

from insufficient proteids, 103. 

from excess of fat, 36, 80. 

from excess of carbohydrates, 36, 78. 

from excess of proteids, 36, 83. 
Measles, 174. 
Mcdiastinitis, 208. 

Meningitis, 72, 125, 128, 132, 134, 135, 
142. 149, 181, 233, 273, 276, 287. 

cerebrospinal, 44, 47, 125, 126, 129, 
132, 135, 136, 143, 181, 233. 

serous, 276. 

tubercular, 44, 66, 86, 125, 126, 129, 
132, 135, 143, 282, 283. 

cerebrospinal fluid in, 126, 127. 
Meningocele, 20. 
Multiple neuritis, 109. 
Myelitis, 279. 
Nephritis, acute, 220, 223, 225. 

chronic, 221. 

chronic interstitial, 220. 

chronic parenchymatous, 220. 

degenerative, 122, 215. 
New-born, cerebral hemorrhage in, 268, 
276, 279. 

hemorrhagic disease of, 23. 

septic infection of, 12, 27, 276. 
Orthostatic albuminuria, 220, 221. 
Osteomyelitis, 109, 147, 295. 
Otitis media, 47, 134, 153, 154, 161, 

163, 231, 290. 
Pancreatization (see infant feeding). 
Paralysis, cerebral, 15, 279. 

diphtheritic, 293. 

facial, 15. 

hysterical, 295. 

infantile, 15, 109, 279, 282, 283, 285, 
287, 292, 295. 

obstetric, 15, 16. 

peripheral, 287, 293. 
Paraplegia, 278, 279. 
Pasteurization (see infant feeding). 
Pelvic inflammation, 122. 
Pericarditis, chronic adhesive, 205, 209, 

215- 

dry, 204. 

with effusion, 204. 
Periosteitis, 109, 147, 295. 
Peritonitis, chronic serous, 119. 



general, 27, 90, 177. 

malignant, 119. 

tubercular, 119, 123, 236. 
Pleural adhesions, 209. 
Pleurisy, purulent, 185, 189. 

serous, 184, 185, 189. 
Pneumonia, 18, 47, 89, 134, 135, 136, 
142, 143, 160, 177, 178, 181, 184, 
185, 187, 188, 189, 197, 233, 290. 

unresolved, 188. 
Poliomyelo-encephalitis (see poliomye- 
litis). 
Poliomyelitis, 15, 109, 279, 282, 283, 

285, 287, 292, 295. 
Pott's disease, 106, 109. 
Proteids (see infant feeding). 
Purpura, 304. 
Pyelitis, 231, 233, 234. 
Pyloric stenosis, 39. 
Pyonephrosis, 236. 
Reflex convulsions, 261, 262, 264. 
Rheumatism, 109, 147, 200, 201, 204, 

208, 287, 295. 
Rhinitis, diphtheritic, 138, 149. 

simple, 137, 149, 154, 165. 

syphilitic, 137, 149, 150. 
Rickets, 61, 80, 98, 105, 155, 163, 165, 

166, 244, 245, 273, 299, 301. 
Sarcoma of brain, 291. 

of kidney, 112, 223, 236. 

of liver, 218. 

of suprarenal capsule, 218. 
Scarlet fever, 47, 134, 142, 143, 181, 

220, 248. 
Scurvy, 110, 113, 146, 241, 294. 
Septic infection of new-born, 12,27, 276. 
Spasmophilic diathesis, 165, 166, 264, 

273- 
Starch (see infant feeding). 
Starvation, 102, 115. 
Stridor, congenital laryngeal, 33, 165. 
Sugar (see infant feeding). 
Suprarenal capsule, sarcoma of, 218. 
Syphilis, congenital, 12, 18, 23, 29, 102, 

137, 150, 215, 254, 291, 295. 
Taches cerebrales, 132. 
Testicle, undescended, 30. 
Tetanus, 273. 
Tetany, 165, 273. 
Thymus, enlargement of, 18, 33. 
Tonsillitis, 47, 134, 142, 143, 180. 



3H 



INDEX. 



Tonsils, hypertrophy of, 155. 
Toxemia, intestinal, 89, 128, 262, 276. 
Tuberculin test, 102, 120, 174, 185, 209, 

215, 254, 291. 
Tuberculosis, of brain, 291. 

chronic diffuse, 69, 102, 163, 195, 

254- 
of hip, 109. 
of kidneys, 1 12, 223. 
of liver, 215. 

of lungs, 174, 184. 185, 188. 
of meninges (see meningitis), 
of pericardium, 209. 
of peritoneum, 119, 123, 236. 



of spine, 106, 109. 

family history of, 123. 

history of exposure to, 123. 
Tumor, abdominal, 122, 235. 

cerebral, 291. 

mediastinal, 33. 
Typhoid fever, 125, 135, 136, 230. 
Uric acid, crystals in urine, 112. 
Vomiting, nervous, 41, 44. 

recurrent, 41, 44, 66, 222, 223. 
Whey (see infant feeding). 
Whey proteids (see infant feeding). 
W T hooping cough, 174. 
" Worms," 69. 



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